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Structured Education for Type 2 Diabetes
Patient Details
Title *
Full Name *
Date of Birth *
Telephone Number *
Address *
Postcode *
Sex *
Male
Female
NHS Number *
Overseas visitor? *
Yes
No
Date of Diagnosis *
Consent
Does the patient give consent for their medical record to be shared with their GP practice? (Helps us to gain their recent biomedical information if they are only just having them done at time of referral) *
Yes
No
Does the patient give consent to receive text message reminders? (reminders to attend sessions ONLY) *
Yes
No
Communication
What is the patient’s main spoken language? *
Is an interpreter needed? *
Yes
No
Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *
Yes
No
What might be helpful when communicating with this patient or their parent/carer? *
Type of Diagnosis
Please select the required Structured Education module
Newly Diagnosed (diagnosed within last 6 months)
Foundation (diagnosed longer than 6 months)
Do you require us to refer this patient to PALS *
Yes
No
Biomedical data (Ignore if agreed to consent data above)
HbA1c (mmol/mol/%)
BP (mmHg)
Total cholesterol (mmol/l)
HDL Cholesterol
LDL Cholesterol
Current Medication
Metformin - Name and Dosage
Sulphonlyurea - Name and Dosage
Glitazone - Name and Dosage
Insulin - Name and Dosage
Any others, please specify
Referrer Details
Referred By *
Email address *
Contact Number *
Registered GP *
GP Address *
GP Telephone Number *
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