Patient Details

Title *

Full Name *

Date of Birth *

Telephone Number *

Address *

Postcode *

Sex *

Male

Female

NHS Number *

Overseas visitor? *

Yes

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

Does the patient give consent to receive text message reminders? (reminders to attend sessions ONLY) *

Yes

Communication

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

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

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

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 *

Structured Education for Type 2 Diabetes