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Diabetes Education Referral Form

To make a referral to ISCH, please fill out the information below.

Referrer Details

Referrer Name*

Referrer Organisation*

Referrer Position*

Referrer Phone*

Referrer Email

Referrer Fax

Client Details

Client Family Name*

Client Given Names*

Client Date Of Birth (dd/mm/yyyy)*

Client Gender*

Client Home Address*

Client Contact Phone Number*

Alfred UR

Client Country of Birth*

Is the client of Aboriginal or Torres Straight Islander origin?*
Does the client have a refugee status?*
YesNoNot stated/unknown
Does the client require an interpreter?*
If yes, please state preferred language

Is the client living in insecure housing?*
Client Medicare Number* (Enter NA if not available)

Please give details of the client's current GP (GP name, Practice name, Address, Phone)*

Does the client hold any of the following concession cards?*
Pension ConcessionDisability SupportHealth Care CardNot stated/unknown

Diabetes Referral Questions

The above patient was:* SeenNot Seen
by the Diabetes Education team at the Alfred hospital during their admission in


Reason for community referral

Please specify the details*

Please indicate the reasons below.

Diabetes Duration


Insulin / Other Injections

Steroids / Other Medications



Medical History

Social / Work Situation



Education provided at The Alfred*
Nil/Not SeenSelf-blood glucose monitoringInsulin therapyNDSS registrationSelf administration of Insulin/ByettaHypoglycaemia MXDiabetes and DrivingAlcohol and DiabetesSteroids and DiabetesScreeningDiabetes and Foot Care



Ongoing Education Needs


Follow up

Follow up in Alfred Diabetes Clinic required* YesNo Date of Follow Up


Assessment/Care Plan

Please tick below if you have an Assessment and/or Care Plan and would be happy for ISCH to contact you to obtain a copy. Alternatively, you can attach them below.
AssessmentCare Plan
Please attach an Assessment and/or a Care Plan if available

Does the client give consent to a referral to Inner South Community Health?*

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