GLOUCESTERSHIRE HOSPITALS NHSFT SPECIALIST DIABETES REFERRAL FORM
Patient Details
SURNAME
FIRST NAME
ADDRESS
NHS NUMBER
TELEPHONE
NUMBER
DATE OF BIRTH
REFERRED BY
GP NAME & TEL
PRACTICE NAME
GP FAX NUMBER
ETHNICITY
ENGLISH SPOKEN
Exclusion Criteria:
1. Not registered with a Gloucestershire GP
2. Stable/non-complex T2
Please tick reason for referral
Assessment/management of
Specialist nephropathy (incl. those on dialysis)
those on Insulin Pump Therapy
Specialist diabetic footcare
Specialist antenatal diabetes care (women with diabetes
contemplating pregnancy or who are pregnant)
Type 1 diabetes for: 1)children
Other reason for referral – e.g. significant or worsening
(incl. transition) and 2) those
complications requiring acute/specialist input (please
with poor blood glucose control
provide information below)
Investigations / Bloods
HbA1c
Total cholesterol
eGFR
HDL
ACR
LDL
Other Significant Information
BMI
Weight
Serum albumin
ALT
Alkaline phosphatase
BP
Macro and Micro Vascular Complications
Myocardial infarction or angina
Retinopathy
Coronary artery bypass grafts
Neuropathy
AAA
Erectile dysfunction
Stroke
Nephropathy
Other Conditions - please tick below to indicate co-morbidity
Thyroid dysfunction
Other
Anaemia
Dementia
Asthma / Chronic obstructive pulmonary disease
Mobility problems*
Mental health or LD disorders*
Other specialist services*
Housebound
None
*PLEASE INCLUDE DETAILS IN REASON FOR REFERRAL OVERLEAF
Review date: February 2016
Reason for referral:
Please note that both the GCS Community Diabetes Team and GHFT Diabetes & Endocrinology Advice &
Guidance remain an option for those patients who do not fulfil the above criteria but maybe considered complex
due to intercurrent illnesses or ther complicating factors; this may still result in a referral to the hospital specialist
team
PLEASE ATTACH SUMMARY SHEET WITH PMH AND
CURRENT REPEAT MEDICATION
Review date: February 2016