General Practice Referral Form 	

Patient Details	

Referral Date	<TodaysDate>	Does your patient speak English? <Does your patient speak english?>	 <Yes>Yes  <No>No	
Name	<PtFullName>	What is the main language spoken at home?  <PtPrefLang>	
Address	<PtStreet>	Aboriginal or Torres Strait Islander descent: 	<Aboriginal or Torres Strat Islander Descent?> <Yes - Aboriginal or Torres Strait Islander>Yes	 <No - Not Aboriginal or Torres Strait Islander>No	
	<PtCity><PtPostcode>	Current smoker? <Current Smoker?><Yes - Smoker> Yes	<No - Non Smoker>No	
Phone	<PtPhoneMob>	Blood pressure:<Blood Pressure>	 <BPSystolic>    systolic/ 	<BP Diastolic>  diastolic	
Email		Waist circumference (cm):<Waist Circumference> <Waist Circumference>	
DOB	<PtDoB>	Gender	<PtSex>		
Country of birth	<PtCoB>				
Cultural background:	<PtEthnicity>				
Past Medical History/Examinations	<SelectedPMH>
<Ix>	

Life! program exclusion criteria: • Diabetes • Active Cancer • Cardiovascular Disease (CVD) diagnosis in the last 3 months. It is important to consider the suitability of the Life! program for each individual.	

Patient Eligibility<Patient Eligibility>	
Choose one of the following  A  OR  B  OR  C
<A> A	<= 18 years and AUSDRISK = 12 and BMI 25kg/m2 (patient self identifies as being of Asian background a BMI - 23kg//m2 is acepted)>		<B>B	<B - 45 years or over, or = 30 years and of Aboriginal and/or Torres Strait Islander descent and have an intermediate or high risk score when referred by a GP clinic.>		<C>C	<= 18 years with one or more of the following pre-existing conditions>	
≥ 18 years and AUSDRISK ≥ 12
and BMI ≥ 25 kg/m2 (if patient self-
identifies as being of Asian background 
a BMI - 23kg//m2 is accepted)*
<PATIENT ELIGIBILITY A ======= AUSDRISK, Height, Weight, BMI = 18 years and AUSDRISK = 12 and BMI = 25 kg/m2 (if patient self->
AUSDRISK Score:	
<AUSDRISK>	

Height (cm):	
<Height>	

Weight (kg):	
<Weight>	

BMI:	
<BMI>	

MBS items apply for a health assessment:
701, 703, 705, 707, 715	

		45 years or over, or ≥ 30 years and of Aboriginal and/or Torres Strait Islander descent and have an intermediate or high risk score when referred by a GP clinic.
<PATIENT ELIGIBILITY B ===== CVD Risk Score - 45 years or over, or = 30 years and of Aboriginal and/or Torres Strait Islander descent and have an intermediate or high risk score when referred by a GP clinic.>
CVD risk category:	
<CVD Score>	

The following time-based
MBS item applies for a heart
health check: 699, 177	

		≥ 18 years with one or more of the following pre-existing conditions
(Please tick  þ  and document): <PATIENT ELIGIBILITY C =============== = 18 years with one or more of the following pre-existing conditions Cardiovascular disease, Predibetes IFG or IGT, Chronic Kidney Disease, Polycistig ovary syndrome, Familial hypercholesterolemia>
<Cardiovascular disease>Cardiovascular disease*	
 <Pre-diabetes (IFG or IGT)>Pre-diabetes (IFG or IGT)	

<Chronic Kidney Disease>Chronic Kidney Disease	
<Gestational diabetes>Gestational diabetes	

<Polycystic ovary syndrome>Polycystic ovary syndrome	
 <Familial hypercholesterolemia>Familial hypercholesterolemia	

¨ Serum total cholesterol > 7.5mmol/L (initial reading):	
<¨ Serum total cholesterol > 7.5mmol/L (initial reading):>	

¨ Syst BP of ≥ 180 mmHg or Diast BP ≥110mmHg (reading): 	
<¨ Serum total cholesterol > 7.5mmol/L (initial reading):>	

For further information or clariﬁcation, please refer to the deﬁnitions page.	

Referrer Details	

Name	<DrName>	<Patient Consent>
 <Yes, patient consents to be enrolled in the program>Yes, patient consents to be enrolled in the program
<Blood pathology report within 12 months of referral date*>Blood pathology report within 12 months of referral date*
<Fasting Blood Glucose> Fasting Blood Glucose
<Lipid Profile (TC/TRIG/HDL/LDL)>Lipid Profile (TC/TRIG/HDL/LDL)
<Completed AUSDRISK form if using criteria A>Completed AUSDRISK form if using criteria A
<Diabetes excluded*> Diabetes excluded*
<Yes, patient is happy for Life! to contact them for research or about their experience in the program.>Yes, patient is happy for Life! to contact them for research or about their experience in the program.
<Yes, patient is happy for Life! to contact them to discuss participation in social marketing activities.>Yes, patient is happy for Life! to contact them to discuss participation in social marketing activities.
*For further information or clariﬁcation, please refer to the deﬁnitions page.
	
Clinic	<Practice>		
Address	<DrStreet>		
			
Phone	<DrPhone>		
Fax	<DrFax>		
Email	<DrEmail>		

By signing this form, you agree that you have explained to your patient and, in your opinion, they understand that Diabetes Victoria collects their personal information for the purposes of Life! program registration, administration, participation, monitoring and evaluation.
	
Signature:	Electronically signed by 
<DrDetails>	Return completed referral to: 
Email: life@diabetesvic.org.au or Fax: (03) 96671757	

Definitions	

A.   AUSDRISK + BMI		Serum cholesterol >7.5 mmol/L
If on medication managing the condition, patient is still eligible for 
the program.
Systolic BP ≥ 180mmHg or diastolic BP ≥ 110mmHg8
If on medication managing the condition, patient is still eligible for 
the program.
Polycystic Ovarian Syndrome9
Rotterdam diagnostic criteria. Requires two of: 
• 	Oligo- or anovulation 
• 	Clinical and/or biochemical hyperandrogenism 
• 	Polycystic ovaries on ultrasound (and exclusion of other aetiologies)
	
The Australian type 2 diabetes risk assessment tool (AUSDRISK) is a short list of questions to help assess a person’s risk of developing type 2 diabetes over the next five years.
https://www1.health.gov.au/internet/main/publishing.nsf/Content/chronic-diab-prev-aus
Body mass index (BMI) is one way to assess whether a person’s weight is in the healthy range. The BMI combines a person’s height and weight to form a measure that can help predict their risk of developing disease.

	weight kg)
Body mass index = 	--------------
	height (m)2
www.aihw.gov.au/reports-statistics/behaviours-risk-factors/overweight-obesity/about
The following time-based MBS items apply for a 
health assessment: 701, 703, 705, 707, 715

Asian sub-regions
Asian background includes three distinct sub- regions (Parliament of Australia, 1997):
Northeast Asia (Mainland China, Hong Kong, Japan, Korea, Taiwan);
Southeast Asia (Brunei, Cambodia, Indonesia, Laos, Malaysia, Burma (Myanmar), the Philippines, Singapore, Thailand, Vietnam); and
Southern Asia (Afghanistan, Bangladesh, India, Pakistan, Sri Lanka, Nepal).			
		Blood Test Results10	
		A patient’s blood test result is required to ensure that type 2 diabetes has been excluded. Please attach patient blood test results within the last 12 months of the Life! referral date. If the patient is currently pregnant and has been diagnosed with GDM, post partum results will be requested once the patient is enrolled in the program. 
• 	Full Blood Lipids 
• 	Fasting Blood Glucose (FBG) or HbA1c 
Further testing to exclude type 2 diabetes 
• 	If FBG is 5.5 - 6.9 mmol/L an Oral Glucose Tolerance Test (OGTT)
	 is recommended. 
These are via venous sampling under laboratory methodology.	
		Diagnostic criteria for type 2 diabetes (RACGP clinical guidelines 2016-2018)11	
B. Cardiovascular risk score		Patient is excluded from the program if they meet one or more of the following: 
• 	Fasting blood glucose (FBG) ≥7.0 mmol/L or random blood 	glucose ≥11.1 mmol/L confirmed by a second abnormal FBG on a 	separate day 
• 	Oral glucose tolerance test (OGTT) before (fasting) and two hours 	after an oral 75 g glucose load is taken. Blood glucose is measured. 	Diabetes is diagnosed as FBG ≥7.0 mmol/L or two hour blood 	glucose ≥11.1 mmol/L 
• 	Glycated haemoglobin (HbA1c) ≥48 mmol/mol (6.5%; on two 	separate occasions) 
These are via venous sampling under laboratory methodology.	
The Australian CVD risk calculator combines several risk factors to calculate a risk score (expressed as a percentage), which is a person’s chance of having a CVD event such as a heart attack or stroke in the next five years. www.cvdcheck.org.au			
C. Pre-existing conditions			
Cardiovascular disease*		
•	Acute rheumatic fever/ 		•	Chronic Heart Failure
	rheumatic heart disease 		•	Coronary Heart Disease
• 	Angina 				•	Myocardial infarction
• 	Angioplasty 			•	Peripheral Vascular Disease
• 	Arrhythmias/Atrial fibrillation 	•	Stroke
• 	Cardiomyopathy 
*Must not have been diagnosed within the last 3 months. 
*Must be medically stable and must not have had a hospital admission in the last 12 months for the condition.
 Gestational diabetes 
To participate in the program, women must not be pregnant. 
Moderate or severe kidney disease2 
• Persistent proteinuria or GFR < 45mL/min/1.73m2 or 
• Stage 3b chronic kidney disease or greater 
Pre-diabetes3 4 5 6 
Blood glucose levels are higher than normal but not high enough to be classified as diabetes. 
• Impaired Fasting Glucose (IFG) 
	Blood glucose levels are escalated in the fasting state but not high 	enough to be classified as diabetes. It is diagnosed on the basis of 	a result between 6.1 and 6.9 mmol/L 
• Impaired Glucose Tolerance (IGT) 
	Blood glucose level is higher than normal two hours after an 	OGTT but not high enough to be diagnosed with diabetes. Two-hour 	plasma glucose is between 7.8 and 11.0 mmol/L. Fasting blood glucose level may still be in the normal range. 
• Glycated haemoglobin (HbA1c) 
	Pre-diabetes can be diagnosed with a HbA1c of 6.0-6.4% 
Familial hypercholesterolemia7 
The Dutch Lipid Clinic Network Score Criteria required for diagnosis.
			
		Additional Information	
		If you refer your patient while they are pregnant, please note that they will not be able to commence the program until they are at least 6 weeks postpartum. Both the referrer and the patient will be updated on the progress of the referral.	
		1. Heart Foundation www.heartfoundation.org.au/bundles/your-heart
2. Kidney Health kidney.org.au/health-professionals/ckd-management-handbook
3. Diabetes Australia www.diabetesaustralia.com.au/about-diabetes/pre-diabetes/
4. National Diabetes Services Scheme www.ndss.com.au/understanding-pre-diabetes
5. Royal Australian College of General Practitioners LTD (RACGP) www.racgp.org.au
/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/
guidelines-for-preventive-activities-in-general-pr/preamble/introduction
6. RACGP www.racgp.org.au/your-practice/guidelines/diabetes/3-screening,-risk assessment,-case-finding-and-diagnosis/33-impaired-fasting-glucose-or-impaired glucose-tolerance/
7. Familial Hypercholesterolemia Australasia Network www.athero.org.au/fh/patients/
diagnosis/
8. Heart Foundation www.heartfoundation.org.au/bundles/for-professionals/hypertension
9. Jean Hailes for Women’s Health www.jeanhailes.org.au/health-a-z/pcos
10. RACGP https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp guidelines/view-all-racgp-guidelines/diabetes/preventing-progression-to-type-2-diabetes

Data Collection at Diabetes Victoria Diabetes Victoria is the leading charity and peak consumer body working to reduce the impact of diabetes. Data will be collected by Diabetes Victoria on all individuals referred to the Life! program. To maintain the confidentiality of your personal information, we comply with all Commonwealth and State privacy legislation. A copy of our Privacy Policy is available upon request. Your information will be used to assess the effectiveness of the Life! program. It will be stored in a secure database and only accessible by the organisation providing the Life! course and management of the Life! program. Diabetes Victoria ABN 47 008 529 461		

The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK)
The AUSDRISK tool estimates your risk of getting type 2 diabetes in the next 5 years  <The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK)>	

1. Your age group: <1. Your age group>
	Under 35 years 	<Under 35 years - 0 points> 0 points
	35 – 44 years	 <35-55 years 2 points>2 points
	45 – 54 years	<45 - 54 years - 4 points> 4 points
	55 – 56 years	<55- 56 years - 6 points> 6 points
	65 years or over 	<65 years or over - 8 points> 8 points

2. Your gender <2. Your gender>
	Female 	<Female - 0 points> 0 points
	Male	<Male - 3 points> 3 points

3.Your ethnicity/country of birth  <Your ethnicity/country of birth>Y
	a.Are you of Aboriginal, Torres Strait Islander, Pacific  Islander or Maori descent?  <3. Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent?>	
		No		<No - 0 Points> 0 points
		Yes	<Yes - 2 points> 2 points
	b. Where were you born? <Where were you born>
		Australia	<Australia - 0 points> 0 points
		Southern Europe	<Sourthern Europe - 2 points>2 points
		North Africa	<North Africa - 2 points> 2 points
		Asia (including the Indian sub-continent)	<Asia (including the Indian sub-continent) - 2 points> 2 points
		Middle East 	<Middle East - 2 points> 2 points
		Other	<Other - 0 points> 0 points

4. Have either of your parents, or any of your brothers or 	sisters been diagnosed with diabetes (type 1 or type 2)? <4. Have either of your parents, or any of your brothers or 	sisters been diagnosed with diabetes (type 1 or type 2)?>
	No			<No - 0 points> 0 points
	Yes			<Yes - 3 points> 3 points

5. Have you ever been found to have high blood 
	glucose (sugar) for example, in a health examination, 
	during an illness, during pregnancy? <5. Have you ever been found to have high blood>
	No			<No - 0 points> 0 points
	Yes			<Yes- 6 Points> 6 points

6. Are you currently taking medication for high blood 	pressure? <6. Are you currently taking medication for high blood 	pressure?>
	No			<No - 0 points> 0 points
	Yes			<Yes - 2 points> 2 points

7. Do you currently smoke cigarettes or any other tobacco 	products on a daily basis? <7. Do you currently smoke cigarettes or any other tobacco products on a daily basis?>
	No			<No - 0 points>0 points
	Yes			<Yes - 2 points> 2 points

8. How often do you eat vegetables or fruit? <8. How often do you eat vegetables or fruit?>
	Everyday	<Every Day - 0 points> 0 points
	Not every day	<Not Every Day - 0 points> 0 points	
	9. On average, would you say you do at least 2.5 hours of physical activity per week (for example, 30 minutes a day on 5 or more days a week)? <9. On average, would you say you do at least 2.5 hours of physical activity per week (for example, 30 minutes a day on 5 or more days a week)?>
	Yes		<Yes - 0 points> 0 points
	No 		<No - 0 points> 0 points

10. Your waist measurement taken below the ribs (usually at the level of the 	navel, while standing): <10. Your waist measurement taken below the ribs (usually at the level of the navel, while standing):>
	Waist measurement (cm)  <10. Waist Circumference>

11. Complete either the purple or orange box below, as appropriate: <11. Complete either the purple or orange box below, as appropriate:>

For those of Asian or Aboriginal or Torres Islander descent: <For those of Asian or Aboriginal or Torres Islander descent:>
Men 	Women
Less than 90cm 	Less than 80cm 	<Men Less than 90cm Women Less than 80 cm - 0 points> 0 points
90–100cm 	80–90cm 	<Men 90 -100cm Women 80-90cm - 4 points> 4 points
More than 100cm 	More than 90cm 	<Men more than 100cm Women more than 90cm - 7 points> 7 points	

For all others: <For all others>
Men 	Women
Less than 102cm 	Less than 88cm 	<Men - Less than 102cm Women - Less than 88cm - 0 points> 0 points
102–110cm 	88–100cm 	<Men - 102 - 110cm Women - 88-100cm - 4 points> 4 points
More than 110cm 	More than 100cm 	<Men - more than 110cm Women - more than 100cm - 7 points> 7 points

Add up your points :  <AUSDRISK Total Points>
	
		5 or less: Low risk	

Approximately one person in every 100 will develop diabetes.	

6–11: Intermediate risk	

For scores of 6–8, approximately one person in every 50 will develop diabetes. For scores of 9–11, approximately one person in every 30 will develop diabetes	

12 or more: High risk	

For scores of 12–15, approximately one person in every 14 will develop diabetes. For scores of 16–19, approximately one person in every seven will develop diabetes. For scores of 20 and above, approximately one person in every three will develop diabetes	

Your risk of developing type 2 diabetes within 5 years*:

*The overall score may overestimate the risk of diabetes in people younger than 25.

The Australian Type 2 Diabetes Risk Assessment Tool was originally developed by the International Diabetes Institute on behalf of the Australian, State and Territory Governments as part of the COAG Diabetes reducing the risk of type 2 diabetes initiative