COMMUNITY DIABETES SERVICES REFERRAL FORM PLEASE COMPLETE IN FULL TO AVOID DELAY Fax Routine referrals to 01582 709092 or 700225 For URGENT referrals TELEPHONE 01582 709094 or 700320 to discuss before faxing PATIENT DETAILS GP AND RERERRER DETAILS Mr/Mrs/Ms/Miss Date of referral: Surname: Referrer if not GP: First Name: Designation: DOB: Age: NHS No. Tel: Address: GP: Tel: Mobile: Email: Ethnicity: Speaks fluent ENGLISH: YES * NO Practice Address: * Urdu * Bengali * Tel: Fax: TYPE OF REFERRAL – for brief description of each service see overleaf STRUCTURED EDUCATION FOR PEOPLE WITH TYPE 2 DIABETES (or IFG/IGT) * * * * * * * DESMOND * (also for IFG or IGT) DESMOND Foundation* Living with Diabetes in URDU Living with Diabetes in BENGALI S.M.I.T.H.* (include patient summary) Carbohydrate Awareness Programme* Living with Diabetes for HOUSEBOUND 1:1 in English, Urdu or Bengali *Denotes MUST be fluent in English 1:1 DIABETES SUPPORT * * * Diabetes DSN Review clinic Tick if also Housebound * Tick if also Insulin start * Diabetes Specialist Dietitian HOUSEBOUND Routine Diabetes Review For all the above referrals please include with referral a print out of patient summary, including medication, medical history and allergies. Interpreter required: YES * NO * Language ……………………………………………… Does Patient Have? * * * * Type 1 Diabetes Type 2 Diabetes Impaired Fasting Glucose (IFG) Impaired Glucose Tolerance (IGT) RESULTS Date of Diagnosis Smoker DATE **HbA1c **Cholesterol **HDL **Blood Pressure **Waist Circumference Weight (Kgs) **LDL **This information is required to facilitate education, if not supplied, referral will be returned (HbA1c not required if IFG or IGT Reason for referral and additional information: Retinopathy Yes * Ex. * Never * If smoker, stop smoking support offered: YES * NO * Ht (cms) BMI Referred: YES * NO Last date screened: Results: * GP to sign below if referring for insulin start or titration of insulin or oral medication. Please see copy of clinical protocol for adjustment of oral medication, insulin start and insulin titration: Signature: Please print name: G:\Luton Community Services\ADULT COMMUNITY HEALTHCARE\Community Diabetes Services\Spec for SERVICE\Master PDF created with pdfFactory Pro trial version www.pdffactory.com