MDP
Multidisciplinary Diabetes Program
Fax referrals to 9201 0033
Date of Referral: __________________________________
General Practitioner: (Stamp)
Name:
Address:
Phone no:
Fax no:
Email:
GP Signature:
Patient details:
Name:
Gender:
 Male
 Female
Address:
Phone no:
Mobile:
DOB:
Aboriginal or TSI:  Yes
 No
Type of Diabetes:
 Type 1
 Type 2
 At risk Type 2
 At risk/newly diagnosed CHD
 Type 2 on insulin
 IGT/ IFG
 Microalbuminuria
Year diagnosed _________________
Registered with NDSS? ``` Yes
 No
Suitable for Group Education?  Yes
 No
Yes
No If yes, language required ___________________
Current treatment:
 Lifestyle only  Lifestyle and tablets
 Lifestyle, tablets and insulin  Lifestyle and insulin
Please list current medications or attach:
__________________________________
__________________________________
__________________________________
 Other
Other medical conditions:
 Heart disease
 High blood pressure
 Kidney disease
 Eye problems
 Other _____________________________
Pathology Results (within last 12 months): Date: ________________ or attach
HbA1c
_______ mmol/mol
Urinary Microalbumin _______ mg/L
ACR
_______ mg/mmol
eGFR
_______
Serum Creatinine
________ micromol/L
FULL LIPID PROFILE:
Cholesterol:
TG:
HDL:
LDL:
_______ mmol/L
_______ mmol/L
_______ mmol/L
_______ mmol/L
OGTT (if newly diagnosed) (mmol/L)
Fasting: _____ one hour: _____ two hour: _____
Blood Pressure: ________/________
Other:
Please attach if available:
 GP Management Plan
 Team Care Arrangement
Black Swan Health does not require
GPMP/TCA to accept patient referrals.
My GP has explained the purpose of this assessment and program and I give permission to provide and discuss my medical information with
other service providers who are contributing to my care. I understand that my medical information will remain confidential. Some de-identified data
which will not identify me, my Practice or my GP, will be given to the Commonwealth Department of Health and Ageing to enable the program to
be evaluated.
Please note: Information may be accessed by accreditation provider Australian Council on Healthcare Standards for accreditation purposes only.
I am aware I will be required to attend Black Swan Health (BSH) for assessment and that BSH are unable to provide transport to the assessment.
I am aware that I may request a copy of the BSH Privacy and Confidentiality statement at any time. I can withdraw from the program at any time.
Patient signature: _____________________________________
Created: [dd month yyyy]
Last modified: [dd month yyyy]
Planned Review Date: [dd month yyyy]