Diabetes Tasmania Clinical Services	

Clinical services are available statewide

Phone: 6215 9000 I Fax: 6215 9099 I HealthLink EDI: diabetas

Referral date: <<Miscellaneous:Date>>

Referrer details:
<<Doctor:Name>>  
<<Practice:Name>>
<<Doctor:Address>> 
Provider number: <<Doctor:Provider Number>>
Phone: <<Doctor:Phone>>  
Fax: <<Doctor:Fax>> 	

Patient details:
Name: <<Patient Demographics:Title>> <<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of birth: <<Patient Demographics:DOB>> Gender: <<Patient Demographics:Sex>>
Address: <<Patient Demographics:Address>>
Phone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>		Ethnicity: <<Patient Demographics:Ethnicity>>
ATSI: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
Language spoken: <<Patient Demographics:Language Spoken>>
Medicare number: <<Patient Demographics:Medicare Number>>
DVA number: <<Patient Demographics:DVA Number>>
Patient consent: <<Patient consent for referral to these services?>>	

Diabetes diagnosis:  <<Diabetes Diagnosis>> 
Years diagnosed:     <<Years diagnosed>>    
Referral discussed:     <<Referral discussed with patient>>	

How we manage appointments: <<How we manage appointments>>

About our services: <<About our diabetes service>>	

Describe currrent needs or goals of care:
<<Describe current needs or goals of care>>	

Injectable medication commencement:  <<Injectable commencement >>
GLP1 type: <<Commencing GLP1>>   
Insulin Type: <<Insulin commencement>>   Dose: <<Commencing dose>>   Frequency: <<Frequency>>   
Insulin Type: <<Insulin commencement 2>> Dose: <<Commencing dose 2>>Frequency: <<Frequency 2>>   	

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

Current and past medical history:
<<Clinical Details:History List>>

Current medications:
<<Clinical Details:Medication List>>

Smoking status: <<Clinical Details:Smoking>>

Please attach relevant pathology: Eg. OGTT HbA1c Total Chol HDL LDL Triglycerides Vitamin D TFT  FBC Micro alb. 
<<Summary:Investigation Results (Selected)>>