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: <<Doctor:Name>> | GP Provider#: <<Doctor:Provider Number>>
Address: <<Doctor:Address Line 1>> <<Doctor:Address Line 2>> <<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>
Email: <<Doctor:E-mail>> | Phone: <<Doctor:Phone>> | Fax: <<Doctor:Fax>>
Patient Information
Family name: <<Patient Demographics:Surname>> | Given Names: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>
Sex: <<Patient Demographics:Gender>> | Date of Birth: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>> | Aboriginal and Torres Strait Islander Status: <<Patient Demographics:ATSI>>
Language spoken at home: <<Patient Demographics:Language Spoken>>
Medicare Number: <<Patient Demographics:Medicare Number>> | Medicare Expiry date: <<Patient Demographics:Medicare Expiry Date>>
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: <<Miscellaneous:Date>>