Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Maternal physiological changes in pregnancy wikipedia , lookup
Electronic prescribing wikipedia , lookup
Fetal origins hypothesis wikipedia , lookup
Prenatal nutrition wikipedia , lookup
Prenatal development wikipedia , lookup
List of medical mnemonics wikipedia , lookup
Referring Physician Contact Information General Internal Medicine Diabetes Clinic 100 West 5th Street, Hamilton, Ontario Phone: (905) 522-1155 Ext.32045 / Fax: (905) 521-6128 Gestational Diabetes Referral Form The information you provide is vital to the selection of the correct management for your patient. PLEASE PRINT Date of Request: ________________________________ Patient Name: ________________________________________________________________________________________________________ Last First Middle Address _____________________________________________________City: ________________________ Postal Code: ________________ Apt. Phone (H): (________)____________________________ Phone (W): ( ________)_______________________________ DOB:____________________________________ Age: _________ Sex: _________ Weight:_____________ kg/ lbs YYYY MM DD ODSB HIN:________________________________________ Version: ____________ NIHB NOTE: PLEASE SPECIFY ANY SPECIAL NEEDS Reason for Referral (Check all that apply) Language/communication barriers? NO YES Education Class and Referral to Endocrinologist (Recommended for GDM) Specify:___________________________________________ Education Class Only (Recommended for IGT) If indicated an individual appt will be scheduled instead of Other Endocrine:____________________________________( please specify) class. Other: ____________________________________________ Diabetes History Co-morbid Conditions Heart Disease Gestational Hypertension Renal Impairment/Proteinuria ____# OF WEEKS PREG Pregnancy Complications:________________________________________________________________ Current Medications: LABS: COMMENTS/OTHER PERTINENT HISTORY: GTT: o 50g: 1hr________________ o 75g: FBS__________1hr__________2hr__________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Due Date:______________________________ ______________________________________________________ Requesting Physician: X _________________________________ Specialty: ______________________________________ Signature: X ________________________________________________ OHIP Billing #: _______________________________________ Family Physician: ____________________________________________