Patient Details		

Referral Date	<TodaysDate>		Does your patient speak English? 	¨ Yes	¨ No	
Name	<PtFullName>		What is the main language spoken at home?  	
Address	<PtStreet>		Aboriginal or Torres Strait Islander descent: 	¨ Yes	¨ No	
	<PtCity> <PtPostcode>		Past Medical History	
Phone	<PtPhoneMob>		<Medical History>	
Email	<PtEmail>			
DOB	<PtDoB>	Gender	<PtSex>		Current smoker? 	¨ Yes	¨ No	
Country of birth	<PtCoB>		Blood pressure:	 <BPSystolic>                    systolic/ 	
<BP Diastolic>                             diastolic	
Cultural background:	<PtEthnicity>		Waist circumference (cm): <Waist Circumference>	

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	
Choose one of the following  A  OR  B  OR  C
¨ A			¨ B			¨ C		
≥ 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)*

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.

CVD risk score:	
<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):
¨Cardiovascular disease*	
¨ Pre-diabetes (IFG or IGT)	

¨ Chronic Kidney Disease	
¨ Gestational diabetes	

¨ Polycystic ovary syndrome	
¨ Familial hypercholesterolemia	

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

¨ Syst BP of ≥ 180 mmHg or Diast BP ≥110mmHg (reading): 	

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

Referrer Details	

Name	<DrName>		¨  Yes, patient consents to be enrolled in the program
¨  Blood pathology report within 12 months of referral date*
	¨ Fasting Blood Glucose
	¨ Lipid Profile (TC/TRIG/HDL/LDL)
¨ Completed AUSDRISK form if using criteria A
¨ 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 to discuss participation in social marketing activities.
*For further information or clariﬁcation, please refer to the deﬁnitions page.
	
Clinic	<Practice>			
Address	<UsrAddress>			
				
Phone	<UsrPhone>			
Fax	<UsrFax>			
Email	<PracEmail>			

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:	<Signature>	Return completed referral to: 
Email: life@diabetesvic.org.au or Fax: (03) 96671757	

		

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		

		

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

2. Your gender
	Female 	¨  0 points
	Male	¨  3 points

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

4. Have either of your parents, or any of your brothers or 	sisters been diagnosed with diabetes (type 1 or type 2)?
	No			¨  0 points
	Yes			¨  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?
	No			¨  0 points
	Yes			¨  6 points

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

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

8. How often do you eat vegetables or fruit?
	Everyday	¨  0 points
	Not every day	¨  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)?
	Yes		¨  0 points
	No 		¨  0 points

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

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

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

For all others:
Men 	Women
Less than 102cm 	Less than 88cm 	¨  0 points
102–110cm 	88–100cm 	¨  4 points
More than 110cm 	More than 100cm 	¨  7 points

Add up your 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