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Community Diabetes Education Program of Ottawa
Self-Referral Form
NAME
FIRST NAME(S)
*
Value is required and can't be empty
PREFERRED NAME (if different)
LAST NAME
*
Value is required and can't be empty
ADDRESS
Address
Address Line 2
City
*
Value is required and can't be empty
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code
Telephone number
*
Phone format: (###) ###-####
Value is required and can't be empty
May we leave a voice message when we call you?
Yes
No
Date of Birth
*
Value is required and can't be empty
Email Address
Do you have a primary care provider (a family doctor or nurse practitioner)?
Yes
No
Please provide the name of your provider
Please tell us about yourself so that we can ensure that our program will meet your needs.
1. What type of diabetes do you live with?
*
Type 2
Prediabetes
Type 1
Do not know
Value is required and can't be empty
Do you use an insulin pump?
No
Yes
Do Not Know
2. Do you take medication for diabetes?
No
Yes
If your answer to previous question is yes, select all that apply
Pills
Insulin
Other injectable medication
3. Have you recently started any steroid medication such as Prednisone or Cortisone?
*
No
Yes
Do not know
Value is required and can't be empty
4. Are you checking your blood sugars?
*
No
Yes
Sometimes
Value is required and can't be empty
5. Have you recently (within the last month) had any low blood sugars (less than 4 mmol/L)?
*
No
Yes
Value is required and can't be empty
6. Are you pregnant or planning pregnancy?
*
No
Yes - pregnant
Yes - planning pregnancy
Not Applicable
Value is required and can't be empty
7. Please specify your preferred gender identity:
Male
Female
Intersex
Trans – female to male
Trans – male to female
Two-Spirit
Do not know
Prefer not to answer
Other
Please specify
A diabetes educator from our program will review your information and then someone from our program will call you.
I give permission for a diabetes educator to review my bloodwork through Connecting Ontario. This is to make sure I can receive the best service for my care. I understand that this information will be kept confidential
*
Accept
Decline
Value is required and can't be empty
If you have a health card (including an Interim Federal Health Plan), please share the number
Is there anything else you would like to share with us?
Submit Form