REFERRAL FORM FOR DIABETES CARE
(Please refer patients meeting criteria from the ‘Model of Care’ Document)
PATIENT INFORMATION
NAME:
Forename Middle Names Surname
ADDRESS: Patient address
DOB:
Date of birth
NHS NO:
NHS number
TELEPHONE
Patient preferred telephone
NUMBERS:
TYPE 1
TYPE 2
DATE OF DIAGNOSIS:
OTHER RELEVANT INFORMATION (Attach Summaries where required)
Please provide details of medication history (to include any adverse reactions or contra-indications)
(Free text box – please add sheets as appropriate)
Medication
Current Repeat Issues
Sensitivities and Allergies
Allergies
BIOMEDICAL RESULTS – MOST RECENT`
TEST
1 (Date)
2 (Date)
3 (Date)
4 (Date)
LAST FOUR HbA1C (Mandatory)
COMMUNITY DIABETES TEAM: REASON FOR REFERRAL - Mark all that apply (Please see referral criteria).
SUPPORT FOR SUBOPTIMAL
SEVERE OR RECURRENT MINOR
INSULIN INITIATION/INSULIN
GLUCOSE CONTROL
HYPOGLYCAEMIA
INTENSIFICATION
INITIATION OF NEW THERAPIES
PRE-PREGNANCY COUNSELLING
ASSESSMENT FOR TYPE 1
E.G. EXENATIDE, GLP1
STRUCTURED EDUCATION
REFERRAL TO GOOD 2 GO
MANAGEMENT OF EARLY
NURSING AND RESIDENTIAL HOME
NEUROPATHY AND NEUROPATHY LIAISON AND SUPPORT
DIETITIAN (see additional criteria) OTHER:
DIETITIAN ADDITIONAL CRITERIA(please tick as appropriate)
 Overweight/Obesity when considering insulin or
 Nutrition support for patients on medications
insulin as a therapy
/insulin
 Unstable or poor glucose control despite first line dietary  Pre-pregnancy counselling
Advice
 Carbohydrate awareness education
 Unexplained Hypoglycaemia
 Carbohydrate counting
 Pre-pregnancy counselling
COMPLEX CARE: REASON FOR REFERRAL - Mark all that apply (Please see referral criteria).
UNDER 25 YEARS OF AGE
INITIAL MANAGEMENT OF TYPE 1 UNSTABLE GLUCOSE CONTROL
DIABETES
COMPLEX INSULIN REGIMES;
COMPLEX DIABETES
PREGNANCY
INSULIN PUMPS AND COMPLEX MDI
ADVANCED DIABETIC FOOT DISEASE
PRE-CONCEPTION COUNSELLING
ADVANCE RENAL DISEASE
IN HIGH RISK PEOPLE
ADVANCED NEUROPATHY/
REFERRAL TO TYPE 1 STRUCTURED OTHER:
AUTONOMIC NEUROPATHY
EDUCATION
ADDITIONAL NOTES (to support the above referral criteria where required)
(Free text box – please add sheets as appropriate)
FOR OFFICE USE ONLY
REVIEWER:
OUTCOME
BITES
GOOD2GO
DATE RECEIVED:
TRIAGE
OTHER: