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Diabetes Referral Form

Please fill out the following information to make a referral to BHN.

    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?*

    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?*

     

    Diabetes Referral Questions

    The above patient was:*

    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*

    Date of Follow Up

     

    Assessment/Care Plan

    Please tick below if you have an Assessment and/or Care Plan and would be happy for Star Health 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

    Please attach Diabetes Injectable Medication Referral form if applicable

    Does the client give consent to a referral to Star Health?*

     


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