Referral form for the ‘Eat Smart’ Study
Professor Jennifer Batch – “EAT SMART” Director of Diabetes & Endocrinology Department of Diabetes & Endocrinology Royal Children’s Hospital Herston, QLD 4029 Telephone: (07) 3636 3767 Fax: (07) 3636 9102
Date of Referral:
Attention Prof Jenny Batch:
RE: Parent/guardian: Address: DOB:
Telephone and or mobile: Weight: Height: Body Mass Index: Current Medication: Relevant Medical History:
Behavioural/psychological history: Other
I would like to refer the above patient to the dietary intervention study Eat Smart, run in conjunction with the Children’s Nutrition Research Centre, UQ, and the RCH. I have read the eligibility criteria and believe this child is eligible. I have spoken with this family about the study and they have indicated they are interested and have agreed to be contacted by the Eat Smart research team. Referring Practitioner: Print Name: Referring Practitioner Address: Signature:
*****THANK YOU - Please post or fax to the address above *****