Dietitian Registration and Questionnaire

M3 Nutrition Pre Screen Questionnaire

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Date of birth*

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

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*

Surcharges and Payment*
Cancelation / No Show policy**