SugarRight Diabetes Program - GP Referral 

SugarRight
14 Branyan Street
Bundaberg Qld 4670
Ph: 07 4150 1800
Fax: 07 4150 1889
Medical Objects: XS4670000BE

Patient's Demographic Details:
Full name: 		
Date of birth: 		
Residential address: 		
Phone - home:		work:		mobile:		
Medicare number:		
Name of parent or caregiver (if relevant):		
Preferred language:		Interpreter required:		
Does the patient identify as Aboriginal and/or Torres Strait Islander?:		

Reason for request:

	

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 (e.g. current medications and dosages): 		
Drug allergies: 		
Alcohol, tobacco and other drugs use: 		

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: 		
Height:  		
Weight: 		
BMI: 		
Blood pressure: 		
History of smoking: 		
HbA1c (current and previous): 		
FBC ELFT fasting lipids - cholesterol LDL HDL Tg: 		
Urine Albumin: creatinine: 		

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

Referring practitioner details:
Full name:		
Address:		
Phone:		Fax:		Email:		
Provider number:		
Date of referral:		

Signature: