Durham Region Diabetes Education Program (Dep) Referral Form

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DO NOT COPY THIS FORM
D
R
D
E
P
(DEP) R
F
URHAM
EGION
IABETES
DUCATION
ROGRAM
EFERRAL
ORM
Client Name:_________________________________ M  F 
DOB (dd/mm/yy): ______________________ Age: _________________
Parent/Guardian (if less than 18 years of age):___________________________________ Health Card #: _______________________________
Address:_____________________________________________________________________________________________________________
Phone (Home): ___________________________ Phone (Work): ___________________________ Phone (Cell): ________________________
’
C
P
DEP L
A
:
LIENT
S
REFERRED
OCATION TO
TTEND
 L
H
– P
P
 L
H
– W
 L
H
– C
H
C
AKERIDGE
EALTH
ORT
ERRY
AKERIDGE
EALTH
HITBY
AKERIDGE
EALTH
OURTICE
EALTH
ENTRE
F
906-665-2404 (T
2 O
)
F
905-665-2404 (TYPE 2 ONLY)
F
905-665-2404 (TYPE 2 ONLY)
AX
YPE
NLY
AX
AX
 M
S
– U
 R
V
– A
/P
S
 R
V
– C
S
ARKHAM
TOUFFVILLE
XBRIDGE SITE
OUGE
ALLEY
JAX
ICKERING
ITE
OUGE
ALLEY
ENTENARY
ITE
F
905-852-2460 (TYPE 2 ONLY)
F
905 - 428-5248 (TYPE 2 ONLY)
F
416-281-7020 (TYPE 2 ONLY)
AX
AX
AX
 O
C
H
C
 C
H. B
C
 B
C
H
C
SHAWA
OMMUNITY
EALTH
ENTRE
HARLES
EST
ENTRE
ROCK
OMMUNITY
EALTH
ENTRE
F
905-723-3391 (TYPE 2 ONLY)
F
905-620-0579 (TYPE 1 ONLY)
F
705-432-3039 (TYPE 2 ONLY)
AX
AX
AX
This form must be completed and faxed by Referring Physician prior to client attending the Diabetes Program.
The DEP will contact patient.
 Yes If yes, who? ______________________________________
 No
Is Client currently followed by Diabetes Specialist (Endocrinologist/Internist)?
 Yes
 No
Consult with Diabetes Specialist (Endocrinologist/Internist) requested:
L
H
R
V
O
C
H
C
CHARLES H. BEST CENTRE
Please note Diabetes Specialist (Endocrinologist/Internist) services only available at
AKERIDGE
EALTH
OUGE
ALLEY
SHAWA
OMMUNITY
EALTH
ENTRE
T
D
:
If pregnant check below:
M
H
:
M
H
(
):
YPE OF
IABETES
EDICAL
ISTORY
CHECK ALL THAT APPLY
EDICAL
ISTORY
CONT
Type 1  New
History attached
 Type 1
 Type 1
Nephropathy - Followed by: ________________
 Established
Thyroid Disease
 Type 2
Foot Problems/Wound Concerns
Hypertension (>130/80)
Type 2  New
Neuropathy
 GDM
 Type 1
Dyslipidemia
 Established
Exercise restrictions/Mobility Issues
 IGT of Pregnancy
Cardiovascular disease
 Prediabetes
_________________________________
 Prediabetes
Tobacco Use
Mental Health Concerns
Alcohol Abuse
Sexual Dysfunction
_________________________________
EDC ________________
Retinopathy
Other _________________________________
M
/N
T
EDICAL
UTRITION
HERAPY
 See attached copies.
R
L
D
:
EQUIRED
ABORATORY
ATA
Yes appropriate for group.
Not appropriate for group.
Date: __________ FPG: ___________ casual: ___________
If not, explain why ______________________________________________
Nutrition Recommendations Will be at Dietitian’s Discretion.
Date: __________ 75g OGTT
FPG: ______ 2-hour: _____
Additional Nutrition Considerations:
_________________________________________________________
A1c: _______________
Date: _______________
_________________________________________________________
TC: _______ HDL-C: ______ LDL-C: _______ TC:HDL _______
P
T
D
RESENT
REATMENT FOR
IABETES
Healthy Lifestyle
TG: _______ ACR: ________ Serum Creat: ________
Oral Agents: Type & Dose ____________________________________
eGFR: ______
TSH: ________
____________________________________
____________________________________
Other: _________________________________________________
Insulin pump
Victoza
GESTATIONAL ONLY
Byetta
50g Oral Glucose Screen: Date: _________ 1 hour: ___________
Insulin:
Dosage
OGTT
Type:
am
noon
pm
HS
Date: ________ FPG: _____ 1-hr: _____ 2-hr: _____
A1c: _________
C
OMMENTS
I
I
/C
O
NSULIN
NITIATION
HANGE
RDERS
Dosage
Type:
am
noon
pm
HS
Referring physician: _____________________________________________________________________________________________________________________
print name
signature
phone
date
For DEP office use:
Priority:
1
2
3
4
Date Received at DEP: ____________________________________
This is an electronic document. To obtain the most up to date version of this form please go to the website
under resources professional page.
Nov 2012

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