ARE KETONES PRESENT IN URINE? YES  NO  If YES please take the following action:
If within office hours: Patient to be referred immediately to Fast Track Nurse Led Clinic at NMUH or CFH.
STEP 1: Please discuss case with DSN by phone at NMUH on 020 8887 4238 or at CFH on 020 8375 1967

STEP 2: Please FAX this form directly to the Diabetes Centre at NMUH on 020 8887 4235 or CFH on 0208 375 1967

If outside office hours: Patient to be referred immediately to Accident and Emergency

WHO Diagnosis criteria

2 consecutive venous samples either fasting or random are required to diagnose diabetes.
If osmotic symptoms are present (polydipsia, polyuria) then only one sample is required / Fasting /

Random

≥ 7.0 mmol / l / ≥ 11.0 mmol / l

PATIENT DETAILS

Name

Address / Patient Post code
Contact telephone
Date of Birth
Gender / Male  Female 
NHS Number
GP Name and address
GP Postcode
Ethnicity /

Is transport required? Yes  No 

IfLinkworker required – please state language
PLEASE DO NOT USE THIS FORM TO REFER PATIENTS FOR RETINOPATHY SCREENING
DIABETES HISTORY AND CLINICAL DATA
Date of results / Sodium / T.Cholesterol / AST / Albumin
HbA1c / % / Potassium / Triglycerides / Alk
Phos / eGFR
TSH / Urea / HDL / T Bilirubin / A:C Ratio
T4 / Creatinine / LDL / T
Protein
Blood Pressure: / /
Weight: / Kgs
Height: / M
Waist Circumference: / Cms
Smoking status / Smoker  Non Smoker  Ex Smoker 
Is the patient newly diagnosed diabetes
Yes  No  / Date of diagnosis:
Type of diabetes: Type 1  Type 2  / Patient is aware of diagnosis: Yes  No 
Has patient received EPCT “Living with diabetes” booklet and Diabetes hand held record? / Yes  No 

Pt Name ………………………………………

KNOWN COMPLICATIONS

MI /Angina / CVA / TIA / PVD
Renal / Foot Ulceration / Injury / Retinopathy
Acute Neuropathy / ED
CURRENT MEDICATION
Please state dose and frequency
Oral Hypoglycaemic Agents
Insulin
Other diabetes treatment
(e.g. Exenatide, Sitagliptin)
Lipid Therapy
Anti-hypertensive Therapy
Other

REASON FOR REFERRAL

Date sent………………. Signature…………………………….. Print name……………………………..
ACTION (For office use only)
Date received / Date Accepted / Date triaged
Referral redirected to GP ______ /

Triaged by

/ Details put on RIO Yes  No 

Referral redirected to choose and book

/ Gen. Diabetes  Renal  Other(please state)

Appointment priority (please tick)

/

Urgent (within 1 week)

/

Routine

Appointment made at following clinic:

Nurse Consultant clinic

Preconception clinic

Diabetes Specialist Nurse clinic

Neuro-Vascular assessment

Diabetes Education (Routine / DESMOND)

Podiatrist only
Dietitian only
INCOMPLETE REFERRALS WILL REQUIRE US TO CONTACT YOU BY PHONE FOR MISSING INFORMATION, THIS COULD RESULT IN A DELAY IN PROCESSING YOUR REFERRAL THROUGH THE SYSTEM

DATA PROTECTION CONFIDENTIALITY NOTE

This message is intended only for the use of the individual or entity to whom it is addressed and may contain information that is privileged, confidential and exempt from disclosure under law.

If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is STRICTLY PROHIBITED. If you have received this communication in error, please notify immediately by telephone and destroy the document. Thank you.

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