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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?*
YesNo
 
Does the client have a refugee status?*
YesNoNot stated/unknown
 
 
Does the client require an interpreter?*
YesNo
 
If yes, please state preferred language

Is the client living in insecure housing?*
YesNo
 
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
for  

 

Reason for community referral

Please specify the details*

Please indicate the reasons below.
T1DMT2DMCFRDSIDMHbA1c

Diabetes Duration

OHA's

Insulin / Other Injections

Steroids / Other Medications

 

History

Medical History

Social / Work Situation

 

Education

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

Other

Comments

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?*
YesNo

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