Consumer Name:
REFERRAL OUTCOME
From Agency/Program receiving referral:
Agency/Program: Address: (number) (street)
Date of birth: Address: (number) (street) (suburb/locality) (postcode) Phone: (03)
URN:
Mobile (optional):
To Agency/Program sending referral:
Agency/Program: Address: (number) (street) (suburb/locality) (postcode)
Phone: (03) Mobile (optional): Fax: (03) Email: The consumer above was referred to us by your organisation on outcome:
Phone: (03) Mobile (optional): Fax: (03) Email: and was assessed by this service on with the following
Dietitian Summary Assessment
Diabetes Classification: Type 1 Type 2 IGT Gestational Consultation: Initial Contact Follow-up appointment Did not attend Anthropometric Details Height (cm) Weight (kg) BMI Patient Progress: Weight Loss (kg) Educated Patient on:
Diabetes – definitions & Implications CHO – Sources & Glycaemic Index Distribution of CHO Healthy eating guidelines Dietary Fats Weight Management Cooking Methods/Recipe Modification Supermarket Product Suggestions Reading Food Labels Exercise Artificial Sweeteners Alcohol
Waist circumference (cms) Hip circumference (cms) Pre-Preg Weight (kg) Cholesterol (initial) Date: Cholesterol (current) Date:
Dietary Assessment & Plan/Goals:
Other Issues for consideration:
Name: Signed:
Position: Dietitian Date: