<<Miscellaneous:Practice Letterhead>>

TYPE 2 DIABETES RISK EVALUATION -701, 703, 705, 707 	

Patient’s Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	

Contact Details:		Medicare or Private Health Insurance Details:	
<<Patient Demographics:Full Address>>
Phone: <<Patient Demographics:Phone (Home)>>	Medicare Number: <<Patient Demographics:Medicare Number>>
Health Insurance: <<Patient Demographics:Health Insurance>>	

Details of Patient’s Usual GP:		
<<Doctor:Name>>
<<Doctor:Full Address>>	Phone: <<Doctor:Phone>>	

ELIGIBILITY FOR TYPE 2 DIABETES RISK EVALUATION

If the answer to all of the following questions is ‘yes’ the patient is eligible for MBS item 701, 703, 705, 707

Patient aged 40 – 49 years?							<<Patient aged 40 – 49 years?>>
Patient has completed Australian Type 2 Diabetes Risk Assessment Tool		<<Aus Type 2 Diabetes Risk Assess Tool completed?>>
Patient has scored 12 or more on the Australian Type 2 Diabetes Risk Assessment Tool?	<<Patient scored 12 or more on the Tool?>>
Patient does not have diabetes?							<<Patient does not have diabetes?>>
Patient has not had a Type 2 diabetes risk evaluation claimed in the past 3years ?	<<No risk eval claimed in past 3 years>>
Patient has not had a 45 – 49 year old health check claimed in the past 3years ? 	<<No 45-49 YO health assess claimed in past 3 years>>
(if unsure about previous items claimed contact Medicare on 132 150)

RISK ASSESSMENT SCORE ON THE AUSTRALIAN TYPE 2 DIABETES RISK ASSESSMENT TOOL 

Score:	<<Risk Assessment Score >>	Date: <<Date risk assessment completed>>

	12 or more = high risk of developing diabetes (mandatory for claiming MBS item 701, 703, 705 or  707)
	16-19 approximately one person in every seven will develop diabetes within 5 years
	20+ approximately one person in every three will develop diabetes within 5 years

PAST MEDICAL HISTORY

<<Clinical Details:History List>>

FAMILY HISTORY

<<Clinical Details:Family History>>

MEDICATIONS 

<<Clinical Details:Medication List>>

ALLERGIES

Patient’s Name: <<Patient Demographics:Full Name>>

TYPE 2 DIABETES RISK EVALUATION 701, 703, 705, 707	

Modifiable risk factors	Goals - changes to be achieved	Advice / planned actions 
	
Waist measurement / 
Weight	Waist Measurement

Your current waist measurement =  _________

Ideal waist measurement:
Asian or ATSI descent
Women less than 80cm
Men: less than 90cm

For all others
Women less than 88cm
	Men: less than 102cm 

Your current weight =  __________

Your height =  __________

Your BMI =  __________
Ideal BMI: 20-25 Kg/m2	Options:

1. GP / Practice Nurse to assess and advise on management of risk factors

2. Lifestyle Modification Program (LMP).  Contact Division of General Practice for information on local LMPs

3. Referral to other agencies for support	
Blood pressure	
Your blood pressure = _________

Ideal blood pressure: 
Less than 130/80 mm Hg 	
HeartLine 1300 362 787
http://www.heartfoundation.com.au

Smoking	Smoking status: <<Clinical Details:Smoking>>

Ideal:
Non-smoker	Quitline 131 848 
www.quitnow.info.au
	
Nutrition	Follow the Australian Guide to Healthy Eating, choosing foods from each of the five food groups every day:
•	Vegetables/legumes 		4-7 serves
•	Bread/cereals/rice/pasta		4-6 serves
•	Fruit				2-3 serves
•	Milk/yogurt/cheese		2-3 serves (low fat)
•	Lean meat/fish/poultry/eggs/nuts	1-2 serves	
The Australian Guide to Health Eating
http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-food-guide-index.htm	
Physical activity	
Target: ___________________________________

Ideal:
Exercise at least 30 minutes walking or equivalent 5 or more days per week		
Alcohol intake	Alcohol consumption: <<Clinical Details:Alcohol>>

Recommended: 
No more than 2 standard drinks  in any one day	DirectLine: 1800 888 236	

Patient referred to a Lifestyle Modification Program	Yes/No

Date service completed:	<<Miscellaneous:Date (long)>>