Nutrition Education Clinic - Referral Form
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1
2Food & Nutrition Services
Nutrition Education Clinic (NEC)
Referral Form
Check applicable Site:
Fax #
QEII Health Sciences Centre (QEII)
473-3847
Dartmouth General Hospital (DGH)
465-8597
Hants Community Hospital (HCH)
792-2253
Cobequid Community Health Centre
465-8597 (Hyperlipidemia and Weight Management classes only)
Twin Oaks Memorial Hospital
889-2470
Musquodoboit Valley Memorial Hospital
384-3310
Eastern Shore Memorial Hospital
885-3210
Community Health & Wellness Centre, North Preston
434-4022
Client History: Include information pertaining to patient’s referral (ht, wt, biopsy date, etc.) _____ REFERRAL URGENT
(please check if necessary)
Reason for Referral ___________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medical History ______________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Medications _________________________________________________________________________________________________
Can we safely encourage regular physical activity?
Yes
No
Challenges that would influence learning (i.e. mental/physical)? ____________________________________________________
Clinical Data:
Collection date: __________________________
Is client appropriate for a group?
Yes
No
Requires a support person to attend?
Yes
No
Blood Pressure: _______________________________________
Group Programs:
*Due to referral demand, following offered
Chol: _________________
LDL: ________________ mmol/L
as group sessions
Trig: __________________
BG: _________________ mmol/L
Please check (see next page for site availability)
Living Gluten Free (Celiac Disease Edu)
HDL: _________________
Chol ratio: __________________
Heart Healthy Classes
Weight Management
Height: _____________cm
Weight: __________________ kg
Irritable Bowel Syndrome
Shaking the Salt Habit
Small Bowel Biopsy date confirming Celiac: _______________
Referring Physician: _______________________________________
Please print: ____________________________________
Address: _____________________________________________________________________________________________________
Date (
/
/
): ____________________
Telephone: _____________________
Fax: ______________________
YYYY
MM
DD
OFFICE USE ONLY
Type of appointment:
GRP
HL
IBS
WM
GID
GEN
DE
Celiac
*** Please prepare and maintain a supply of this form as additional copies will not be made available.
CD0056MR_01_12
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Parent category: Medical