Fraser Health Authority Paediatric Diabetes Referral Form Page 2

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FRASER HEALTH AUTHORITY
PAEDIATRIC DIABETES REFERRAL FORM
Date of Referral: ______________________ Date of Diagnosis: _____________________________
□ Type 1 Diabetes New Dx
□
Type 1 Diabetes Transfer of Care
Reason for Referral
□ Type 2 Diabetes New Dx
□ Type 2 Diabetes Transfer of Care
□ Prediabetes New Dx
□
Prediabetes Transfer of Care
Additional information:
□Social or family concerns: _________________________________________________________
□History of recent hospitalization: ___________________________________________________
□Other: ________________________________________________________________________
Patient’s Name: ___________________________________
History and LAB Checklist:
SURNAME, Given name
o Last Consult
o A1C
Date of Birth:
_______/______/______
o FBS, OGTT
(day / month / year )
Gender: □ Male
□ Female □ Transgender □ Other
o TSH, ATPO
o Chol profile
PHN:
___________________________________
o TTG, IgA
o GAD antibodies
Medication(s) : ___________________________________
o Social Work Notes
o Food/Nutrition Hx
Insulin: □ Pen
□ Syringe
□ Pump ___________
o Growth Chart
Pump brand
Parent(s)/guardian’s name(s): ________________________
__________________________________________________
Address: __________________________________________ Postal Code _____________________
Home phone: __________________________
Language Spoken: _____________
Interpreter Required: □ Yes □ No
Work phone: __________________________
Interpreter Booked: □ Yes □ No
Cell phone:
__________________________
Referring Pediatrician: ___________________
Family Physician: _________________________
Phone #: _______________________________
Phone #: ________________________________
Fax #: _________________________________
Fax #: ___________________________________
July 2015

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