Thank you for choosing Sydney Sports Medicine Centre for your Dietetic
consultation. We aim to provide high quality, evidence based, professional
assessment, advice and care.
CANCELLATIONS
We ask that you please provide at least 24 hours notice for all cancellations and rescheduling
of appointments. Cancellation of appointments or failure to attend may attract a cancellation
fee as follows:
• Payment of 100% of the fee if less than 24 hours notice provided
It is not our aim to make profits from cancellation fees, rather to make sure those
appointment times are kept available for others who need them, and in order that you respect
your dietitian’s time.
We do appreciate that, in some circumstances, short notice may occasionally be unavoidable,
and discretion will be exercised in such cases.
_________________________________________________________________________
I have read, understood and accept the dietitian cancellation policy.
Signed _________________________________________ Dated ____________________
Name ________________________________________________________ (please print)
Page
1
INTITAL CONSULT FORM FOR DIETITIANS
All new clients to complete pages 1-5.
Date: ______________________
Name:
Title:
Preferred name:
DOB: Age:
Gender:
Address: (street)
Address: (suburb)
Address: (postcode)
Phone number: (home) (mobile)
Email address:
Occupation:
Health Fund:
Medicare number:
Sport/Exercise:
Coach:
Referred by:
Live with (circle): Alone; partner/spouse; parents/guardians; share with friends; dorm style; other
Please indicate who
does shopping/cooking:
Page
2
Personal Dietary Goals or Issues
1. __________________________________________________________________ _
2. ________________________________________________________________ __
3. ___________________________________________________________________
Exercise Training Schedule OR I do not do regular exercise
Day A.M. training Mid-day training P.M. training
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Dietitian
OR I do not additional
exercise comments:
regularly
Page
3
Medical History
Provide details of any current health problems or illnesses
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Provide details of past health problems or illnesses
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Provide details of any prescription medications
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Dietary Counselling
Provide details of current or past diet therapy (e.g. dietitian, alternative practitioner, weight watchers)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Dietary supplements
List supplements you are currently taking (Brand names also if possible)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Page
4
USUAL Dietary Intake
Please complete this USUAL diet intake as best you can. If you kept a personal food record & have it
with you then omit this section.
Breakfast: Morning Snacks:
Lunch: Afternoon Snacks:
Dinner: Supper or Dessert Snacks:
Additional foods:
Fluids:
Dietitian
additional
comments:
DIETITIAN TO COMPLETE THIS SECTION ONLY
Page
5
DIETITIAN TO COMPLETE THIS SECTION ONLY
Fruit (serves per day) Vegetables (serves per day)
Dairy (serves per day) Fats and oils (serves per day)
Iron rich foods (serves per week) Fast food/eating out (per week)
Treats (occasions per week) Alcohol (std drinks per week)
Weight history:
Measurements:
Dietary & Lifestyle Assessment:
Education:
Management Plan:
Page
6
Review Consultations
Date:
Page
7
Page
8
