Please email completed forms to scwcsu.ncl@nhs.net 
Patient must meet the essential criteria below
•	HbA1c results between 42–47.9mmol/mol (6.0–6.4%), or Fasting Plasma Glucose [FPG] result between 5.5-6.9 mmols/l dated within the last 24 months. If patient has a history of Gestational Diabetes (GDM) then patient is eligible with HbA1c < 42 mmol/mol or FPG < 5.5mmol/l. The previous GDM diagnosis must be indicated under the ‘Referral Information’ section.
•	Patient does not have Type 2 Diabetes - if a reading is in the diabetic range (HbA1c ≥48 or FPG ≥7) the individual is not eligible. If two blood test readings are provided on the referral, and one is in the diabetic range, you will be asked to confirm that the patient is not being treated as diabetic
•	Patient is registered with a GP Practice within North Central London STP, is not pregnant and aged 18 years or over
•	There is no medical reason why this patient should not take part in a programme that includes light-moderate physical activity
Patient details
Title	Title      	Telephone number	Patient Home Telephone      	
First name	Given Name      	Telephone: Can we leave a voicemail?	      	
Surname	Surname      	Mobile number	Patient Mobile Telephone      	
Address	Home Address House Name/Flat Number 
Home Address Number and Street 
Home Address Town 
Home Address County 
     	Mobile: Can we leave a voicemail?	      	
		What is the patient’s first language?	Main Language      	
		Does the patient speak English?	      	
		Date of birth	Date of Birth      	
		Ethnicity	Ethnic Origin      	
Postcode	Home Address Postcode      	Gender	Gender(full)      	
NHS number	NHS Number      	Is the patient on the Severe Mental Illness Register?	      	
Email address	Patient E-mail Address      	Is the patient on the Learning Disability Register?	      	
Referral information
Height measurement (m)	Height      
	
Weight measurement (kg)	Weight      
	
Date of weight measurement	Weight      
	
HbA1c reading (mmol/mol)	HbA1c      
	
Date of HbA1c reading	HbA1c      
	
Fasting Plasma Glucose [FPG] reading (mmol/L)	Single Code Entry: Plasma fasting glucose level       	
Date of FPG reading	Single Code Entry: Plasma fasting glucose level       	
Is there a clinical reason why HbA1c cannot be used to track glycaemic response to the intervention?	     	
Was the patient referred following an NHS Health Check?	     	
Does this patient have a history of GDM?	     	
Patient’s GP details
GP’s surgery name	Usual GP Organisation Name 	Practice code	Usual GP Organisation National Practice Code 	
Surgery address	
Usual GP Full Address (stacked) 
	
Referrer details
Referrer’s organisation	Organisation Name 	
Referrer’s name	Current User 	Referral date	Short date letter merged 	
Consent - confirm the individual understands that:
•	Their personal and medical information is being shared with Xyla Health & Wellbeing so they can participate in the programme
•	Outcome data will be shared securely with their GP
•	Their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act) and NHS guidance (which includes the Caldicott Guidelines)	     	

Please email completed forms to scwcsu.ncl@nhs.net 
END OF REFERRAL FORM