Re: <PtFirstName> <PtSurname>
DOB: <PtDoB>

			SugarRight GP Referral Form

SugarRight Diabetes Management
14 Branyan Street
Bundaberg Qld 4670
Phone No.: 07 4150 1800
Fax No.: 07 4150 1889
Medical Objects: XS4670000BE

Patient's Demographic Details:
Full name: <PtFullName>
Date of birth: <PtDoB>
Residential address: <PtAddress>
Phone - home: <PtPhoneH>   work: <PtPhoneWk>   mobile: <PtPhoneMob>
Medicare number: <PtMCNo> / <PtMCLine>
Name of the parent or caregiver (where relevant): <Name of parent or caregiver (where relevant)>
Preferred language: <Preferred language>
Interpreter required: <Interpreter required>
Does the patient identify as Aboriginal and/or Torres Strait Islander?: <Patient identifies as Aboriginal and/or Torres Strait Islander>

Reason for request:
<Reason for request>

Past Medical History (selected):
<SelectedPMH>

Medication:
<CurrentRx>

Allergies:
<Reactions>

Observations:
<Observations>
Smoking:<SmkStatus>
Alcohol:<AlcHx>

Pathology:
<Ix>

Relevant clinical information about the condition:
<Relevant clinical information about the condition>
Presenting symptoms: <Presenting symptoms (evolution and duration)>
Physical findings: <Physical findings>
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment: <Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment>
Details of any associated medical conditions which may affect the condition or its treatment <Details of any associated medical conditions which may affect the condition or its treatment>

Essential referral information:
<Essential referral information>
Type of diabetes and duration of disease: <Type of disease and duration of disease>
Details of all treatments offered and efficacy: <Details of all treatments offered and efficacy>
Presence of any complications and details when screening last performed: <Presence of any complications and details when screening last performed>

Additional referral information:
Copy of GPMP/TCA attached? <Copy of GPMP/TCA attached?>
Ankle brachial pressure index (ABPI): <Ankle brachial pressure index (ABPI)>
Licence status: <Licence status>
If peripheral neuropathy: B12 folate <If peripheral neuropathy: B12 folate>

Referring practitioner details:
Full name: <DrName>
Full address: <UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <DrEmail>
Provider number: <DrProviderNo>
Date of referral: <TodaysDate>