Title: Microsoft Word - 2188810

Integrated Diabetes Care Case
	Conference Referral Form
MBS items Case Conferencing 735/739/743
Dr Shan Jiang, Dr Danielle Tu

Case conferencing wishes to assist primary care with the management of adult non-pregnant patients with type 2 diabetes.
Case Conferences can be scheduled by sending referrals to SWSLHD-DiabetesCaseConferencing@health.nsw.gov.au
 or by Telephone: (02) 4634 3192.
Name of specialist being referred to: |
Referring Doctor
Doctor's Name: <DrName> | GP Provider#: <DrProviderNo>
Address: <DrAddress Line 1> <DrAddress Line 2> <DrCity> <DrState> <DrPostcode>
Email: <DrEmail> | Phone: <DrPhone> | Fax: <DrFax>
Patient Information
Family name: <PtSurname> | Given Names: <PtFirstName> <PtMiddle Name>
Sex: <PtGender> | Date of Birth: <PtDoB>
Address: <PtStreet> <PtCity> <PtState> <PtPostcode> | Aboriginal and Torres Strait Islander Status: <Indigenous Status>
Language spoken at home: <Language spoken>
Medicare Number: <PtMCNo> <PtMCLine> | Medicare Expiry date: <PtMCExpiry>
PATIENT CONSENT	Obtained 	     Yes ☐	      No ☐
Required Information
Type of diabetes: | Height: | Weight:
Most recent HbA1c result: |
Diabetes medication (please include doses): |
Cardiovascular risk category: | Low | ☐   Medium ☐ | High ☐

Lipid therapy:

Yes
No

☐   If yes details: 
☐

Blood pressure medication:

Yes
No

☐   If yes details: 
☐

Significant comorbidities:

Yes
No

☐   If yes details: 
☐

Episodes of hypoglycaemia:

Yes
No

☐   If yes details: 
☐

Self-monitored BSL:

Yes
No

☐   If yes details: 
☐

End organ damage:

Yes
No

☐   If yes details: 
☐

Please attach the following test results if available and patient summary:

☐ Fasting BSL
☐ T Chol
☐ Triglycerides
☐ HDL-C
☐ LDL-C
☐ eGFR

☐ Albumin Creatinine Ratio (ACR)
☐ BP

Additional information:
Signature: 	Date: <TodaysDate>