Diabetes Referral Form

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

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