Questions 1-10
These questions relate to your child’s personal details, fill in as appropriate.
Question 11
This question asks about who your child has seen regarding their diabetes apart from the GP. Provide details of your child’s consultant. You can also provide details of other professionals your child has seen in question 63.
You may wish to include: your child’s paediatric diabetes specialist nurse (PDSN), psychologist, dietician or anyone else they have seen in relation to their diabetes.
Question 12
This is information specific to your child. Fill in as appropriate.
Question 13
Has your child had tests to diagnose, treat or monitor their condition?
Tick the ‘yes’ box. Include here, HbA1c and any screening tests such as kidney function, eye screening and foot tests. Detail what the tests show. If tests are all clear then write this along with details of when further testing is required.
Question 14
Do you have any reports, letters or assessments etc?
This may include a summary of the last clinic visit or other report from related appointments. If you have such documentation, tick ‘yes’ and provide a copy with your application.
Questions 15 & 16
This is information specific to your child, fill in as appropriate.
Question 17
Statement from someone who knows the child.
If possible have this completed by your PDSN. It is not compulsory, so if no one suitable can complete this, don’t be concerned by leaving it blank.