In-patient Diabetes Education Consultation Form
Patient's Name
*
First Name
Last Name
File Number
*
Type a question
Location (ward, bed)
*
Reason for consultation
*
Newly Diagnosed Type 1 DM
Insulin initiation for Type 2 DM
Insulin Initiation for Gestational DM
Switching from Insulin vials to pens
Switching from pre-mixed insulin to MDI (physician to provide MDI doses to educators)
Recurrent hypoglycemia on insulin
Patient on insulin pump admitted with DKA or with other medical/surgical/obstetric or gynecological issues
Recurrent DKA (3 or more episodes in 6 months) unless already seen during one of these admissions
Other
Date of admission
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Admission Diagnosis
*
Insulin Type (Check ALL that apply)
*
Lantus
Toujeo
Tresiba
Levemir
NPH
Mixtard
Novomix
Humalog mix25
Actrapid
Humulin R
Novorapid
Humalog
Apidra
Insulin Pump
Insulin Doses
*
For example: Lantus 10, NR 8-6-10. For pump write "insulin pump"
Doctor's name
*
Doctor's phone number
*
Department and unit
*
NOTE 1 : Known cases of inadequately controlled T1DM or T2DM who are already on insulin can be referred for outpatient Diabetes Education (First floor, building H, zone 12, DM education OPD).
NOTE 2: Referrals must be sent BEFORE 12 noon. Any referrals after 12 will be seen the next day.
NOTE 3: Referrals should be submitted at least ONE day prior to discharge to allow sufficient time for patient education.
If you have any questions please contact 55159771
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