DPP REFERRAL FORM

** This referral is for Pedi Bridge, Bright Bodies and Lifestyle Intervention Program
**
ADULT PATIENT DEMOGRAPHICS or LABEL CHILD PATIENT DEMOGRAPHICS or LABEL
Name: ______________________________________ Name: _____________________________________
Address: ______________________________________ Address: _____________________________________
Phone: ______________________________________ Phone: _____________________________________
D.O.B. ______________________________________ D.O.B. _____________________________________
Clinic ID: ______________________________________ Clinic ID: _____________________________________

Cell Phone: _____________________________________________________ Cell Phone: _____________________________________________________

Insurance: _____________________________________________________ Insurance: _____________________________________________________
Patient Aware of Referral?  YES  NO Patient Aware of Referral? ð YES ð NO
Language:          Spanish          English      Either          (Please  circle  one) Language:          Spanish          English      Either          (Please  circle  one)

OGTT Individual  YES Parents/Siblings Interested in OGTT?

OGTT Family  YES  YES
Names of family members for screening: Names: ____________________________
___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________
FHCHC Patients? fi YES fi NO" FHCHC Patients? fi YES fi NO"

Lifestyle Intervention Research Program Bright Bodies Program

**Please remember patients are randomized** Children 10-16 years old
Women 18-60 years old Prediabetic (IGT)? fi YES"
Prediabetic? fi YES" Overweight/Obese? fi YES
Tanner Stage: _________
OGTT Date:
OGTT Date: _______________

Referring Clinician (Please Print): ____________________________

      Signature: ____________________________

                  Date: ____________________________
DPG STAFF MEMBER WILL CONTACT THE PATIENT TO SCHEDULE SCREENING WITHIN 2-3 WEEKS UPON RECEIPT OF REFERRAL

PATIENT CONTACTED:  ____________________________________________________

APPOINTMENT DATE: __________________________________________________

Clinician  Reviewed  (Sign):___________________________________                               fi File  in  chart
 DPP REFERRAL FORM
** This referral is for Pedi Bridge, Bright Bodies and Lifestyle Intervention Program
**