Dietitian Registration and Questionnaire

M3 Nutrition Pre Screen Questionnaire

"*" indicates required fields

Title*

Name*

First Last

Date of birth*

Address*

Home Phone

Mobile Phone*

Emergency Contact - Name and Contact Number*

GP Name and Clinic

Insurance Provider If applicable

How did you hear about M3?

M3 Dietitian Questionnaire - Please complete below information prior to your appointment.

Reason for booking/what would you like to discuss with our dietitian

Please list any medical conditions you have:

Is there any major family medical history? E.g. diabetes, cancer, heart disease

Have you ever had any nutrient deficiencies?

Do you have concerns about your bowel habits?

Are you currently taking any medications?

Do you have any food restrictions? E.g. vegetarian, allergies.

For women: do you have a regular menstrual cycle?

How did you hear about our dietitian?

Please bring any recent blood work and a list of current medications with you.

It is useful to bring along a 3 day diet record with you. Be honest and keep it as typical for you as possible. Write down brands and amounts, the more detail the better. If you prefer an app - Easy Diet Diary is recommended, or you can take photos of your food and drinks.

In accordance with the PRIVACY ACT, all information recorded in your files will be kept confidential. Your record will only be accessed by the Practitioner / Instructor providing your care & those office staff responsible for filing. All personnel in this practice are bound to maintain strict patient confidentiality.

Under the PRIVACY ACT, you have the right of access to, and correction of, your personal information. No information will be given to a third party without your consent.

If you have any concerns or complaints about your treatment you may approach any staff member to discuss your concerns. We’re here to help and have policies in place that will deal with your complaint promptly and fairly. You may also request a complaints form from reception.

Informed Consent*
I hereby consent to assessment/treatment as may be necessary in support of my illness, injury or condition. I understand that a full explanation will be given prior to assessment/ treatment. I understand I have the right to decline part or all of my treatment being offered. I understand my right to a second opinion and right to have a support person for all appointments.

Surcharges and Payment*
Yes, I accept charges and are required to pay in full at the time of treatment unless otherwise arranged.

Cancelation / No Show policy**
Yes, I accept If I fail to attend my appointment or cancel within 24-hours i will be charged a No Show or late cancel fee of $40.