Re: <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
DOB: <<Patient Demographics:DOB>>

SugarRight Diabetes Program - GP Referral 

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: <<Patient Demographics:Full Name>>
Date of birth: <<Patient Demographics:DOB>>
Residential address: <<Patient Demographics:Address>>
Phone - home: <<Patient Demographics:Phone (Home)>>  work: <<Patient Demographics:Phone (Work)>>  mobile: <<Patient Demographics:Phone (Mobile)>>
Medicare number: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Name of the parent or caregiver (where relevant): <<Name of the 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 Demographics:ATSI>>

Reason for request:
<<Reason for request>>

Medical history
<<Clinical Details:History List>>

Medication:
<<Clinical Details:Medication List>>

Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>

Observations:
<<Clinical Details:Measurements>>

Smoking: <<Clinical Details:Smoking>>
Alcohol: <<Clinical Details:Alcohol>>

Pathology:
<<Summary:Investigation Results (Selected)>>

Relevant clinical information about the condition:
Presenting symptoms (evolution and duration): 		
Physical findings: 		
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: 		

Essential referral information:
Type of diabetes and duration of disease: 		
Details of all treatments offered and efficacy: 		
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: <<Doctor:Name>>
Full address: <<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Practice:E-mail>>
Provider number: <<Doctor:Provider Number>>
Date of referral: <<Miscellaneous:Date>>