List of Documents

Dietitians:
- Nutritionist/Dietitian Pre-Consultation Form
- Food Frequency Questionnaire
o With this one, I’m thinking it may be easiest to use something
similar to survey monkey (where they just tick the box rather than
having to type something in… thoughts on usability?).
- Single Day Food Diary (will need ~3 of these to be completed by the
patient).
- Single Day Physical Activity Diary (would need >1 of these completed by
patient)
- Post consultation summary report (completed by practitioner after the
session)

Physiotherapists:
- Physiotherapist Pre-consultation Form
- Single Day Physical Activity Diary (would need >1 of these completed by
patient).
- General Exercise Consent Form
- Pre-Exercise Screening Tool
- Post-consultation summary report (completed by practitioner after the
session)

Exercise Physiologists:
- Exercise Physiologist Pre-consultation Form
- Single Day Physical Activity Diary (would need >1 of these completed by
patient)
- General Exercise Consent Form
- Pre-Exercise Screening Tool
- Post-consultation summary report (completed by practitioner after the
session)

Please Note:
- These are the additional documents that will be completed by the patient
and then emailed/accessed by their practitioner once completed.
- As we spoke about before, these should be developed as PDF so the
patient can populate the questions as necessary without having to
download and re-send anything.
- The other information collected as detailed on the “New consult” screens
will be supplementary to this, e.g.:
o Dietitians: Box ticked as to why they’re scouting a Dietitian
o Physios: Box ticked as to why they’re scouting a physiotherapist.
Dropping a pin on the affected area and then describing location,
pain and description of what happened.
o Exercise physiologist: Box ticked as to why they’re scouting an
exercise physiologist.
 Nutritionist & Dietitian Pre-Consultation Form
Nutrition Goals Assessment:

Goals or health concerns to address:

1.
2.
3.

Barriers to addressing the above:

Have you tried diet therapy previously? Yes / No

If yes, please specify: (e.g. dietitian, commercial weight loss program)

Do you have any known food allergies/intolerance? Yes/No

If yes, please specify:

Specific questions I have for this consultation are

Social & Personal Assessment:

Occupation:
--------------------------------------------------------------------------------------------------------

How would you describe your work? Please circle.

Mostly sitting down / Mix of sitting & standing / On your feet most of the day /
Physical labour

Who do you live with at home? Please circle.

Alone Partner Family Friends Dorm-style Other (please specify)

Please specify who prepares and shops for the food in your household

How frequently do you do any physical activity during the week? Please circle.

0-1x/week 1-2x/week 3-4x/week 5-6x/week Daily

Please circle your readiness to make lifestyle changes

1 2 3 4 5
(Not ready) (Somewhat ready) (Completely ready)
 Food Frequency Questionnaire
In the last week, how often would you consume the following:
Breads & Cereals Never Less than 1 1-6 times per 1-3 times per More than 4
Group per week week day times per day
Bread
Cooked rice, pasta,
noodles, Quinoa
Porridge, muesli, cereal
Crumpet, Muffin, scone

In the last week, how often would you consume the following:
Fruit & Vegetables Never Less than 1 1-6 times per 1-3 times per More than 4
Group per week week day times per day
Green or leafy
vegetables
Beans, peas or lentils
Potato, sweet potato,
pumpkin
Other vegetables
Fruit and berries
Diced, dried or canned
fruit
Fruit juice

In the last week, how often would you consume the following:
Protein Food Never Less than 1 1-6 times per 1-3 times per More than 4
Group per week week day times per day
Lean red meat
Lean poultry
Fish fillets or canned
fish
Eggs
Tofu
Nuts, seeds or spreads

In the last week, how often would you consume the following:
Dairy/Alternatives Never Less than 1 1-6 times per 1-3 times per More than 4
Group per week week day times per day
Fresh or powdered milk
Soy, rice or almond milk
Cheese
Yogurt

In the last week, how often would you consume the following:
Sometimes Foods Never Less than 1 1-6 times per 1-3 times per More than 4
Group per week week day times per day
Lollies
Cakes or pastries
Fast food
Alcohol
 Single Day Food Diary
So we can get a better picture about how food fits into your day, please fill out
this diary as accurately as you can. Please give as many details about the food or
drink as possible including type, amount eaten, time of the day, and where.

Daily Food Diary

____/____/____
Time Description of food and drink How much? Where?
(What it is, how much, brand) (E.g. plate/bowl/glass) (E.g. home/cafe)
 Single Day Physical Activity Diary
Daily Physical Activity Diary
____/____/____
Time of Description of physical activity or Duration Intensity
day exercise (How many minutes?) (0-10)
 Physiotherapist Pre-Consultation Form
Physio Goals Assessment:

I am looking for the help of a Physiotherapist because

My health goals are

Things I find challenging to meet my goals are

Please detail any previous muscle, joint or bone problems

Specific questions I have for this consultation are

Social & Personal Assessment:

Occupation:
--------------------------------------------------------------------------------------------------------

How would you describe your work? Please circle.

Mostly sitting down / Mix of sitting & standing / On your feet most of the day /
Physical labour

Who do you live with at home? Please circle.

Alone Partner Family Friends Dorm-style Other (please specify)

How frequently do you do any physical activity during the week? Please circle.

0-1x/week 1-2x/week 3-4x/week 5-6x/week Daily

Please circle your readiness to make lifestyle changes

1 2 3 4 5
(Not ready) (Somewhat ready) (Completely ready)
 Exercise Physiologist Pre-Consultation Form
Exercise Physiologist Goals Assessment:

I am looking for the help of an Exercise Physiologist because

My health goals are

Things I find challenging to meet my goals are

Please detail any previous muscle, joint or bone problems

Specific questions I have for this consultation are

Social & Personal Assessment:

Occupation:
--------------------------------------------------------------------------------------------------------

How would you describe your work? Please circle.

Mostly sitting down / Mix of sitting & standing / On your feet most of the day /
Physical labour

Who do you live with at home? Please circle.

Alone Partner Family Friends Dorm-style Other (please specify)

How frequently do you do any physical activity during the week? Please circle.

0-1x/week 1-2x/week 3-4x/week 5-6x/week Daily

Please circle your readiness to make lifestyle changes

1 2 3 4 5
(Not ready) (Somewhat ready) (Completely ready)
 General Exercise Consent Form

PLEASE READ THEN SIGN THE STATEMENT OF CONSENT:

1. I understand and accept that participating in exercise carries some risk of injury. Yes/No
Other than those previously mentioned, I know of no medical problems that may
increase risk of injury.

2. If any medical or physical condition arises which may influence my ability to Yes/No
participate in the session, I shall inform the health professional. I understand that I
may
be required to receive medical clearance again before recommencing
exercise classes.

3. I have received clearance from my medical practitioner to participate in these Yes/No

exercises.
(If NO, do you intend to seek clearance for participation from your medical Yes/No
practitioner?)

To the best of my knowledge, all information provided is correct.

Signed _________________________________________ Date____________________

Pre-Exercise Screening Tool

Do you have a diagnosed hart condition or family history of Yes No
heart conditions?

Have you ever experienced chest pains at rest or during Yes No

exercise?

Have you ever felt faint or dizzy during exercise that causes Yes No
you to lose balance?

Have you suffered from an asthma attack in the last 12 Yes No

months that required immediate medical attention?

Have you had difficulty controlling your blood sugar levels Yes No
in the last 3 months (Type I and Type II Diabetes only).

Have you been diagnosed with any bone, muscle or joint Yes No
condition that could worsen through exercise?

Do you have any other medical conditions that may increase Yes No
your risk for participating in exercise?

To the best of my knowledge, all information provided is correct.

Signed _________________________________________ Date____________________

 Post-consultation Summary Report
Patient Name:
D.O.B:
Day and Date:
Consultation Type: (Initial consultation or Review)
Reason for referral (If applicable):

Seen by: <Insert practitioners name and qualification letters>

History of Consultation:
<Insert brief overview of what was conducted throughout the session>

Details of patient medical history:

<Insert previous medical conditions, social and family history, medications and
allergies>

Review of symptoms/concerns experienced by the patient:

Assessment:
<Insert details of assessments/tests conducted>

Diagnostic studies:
<Insert objective classification of condition/diagnosis based on data provided>

Recommended treatment:
<Insert treatment plan, and what to review for next consultation>

I authorise that the information provided here is correct and based on true
information obtained throughout the consultation.

Signature _______________________________________________ Date _______________________

 Practitioner Specialty Areas
The following lists have been developed as the search terms for scouting a health
professional in the area.

Dietitians:
Aboriginal/Indigenous Health Diabetes Type II Liver disease Pregnancy and fertility
Aged Care Gestational Diabetes Malnutrition/underweight Private hospital consulting
Allergy and food sensitivity Disability Men’s health Sports nutrition
Arthritis Eating disorders Mental health Swallowing difficulties
Bariatric Surgery Food industry consultant Mindful eating Teaching/lecturing
Breastfeeding (lactation) Food services consultant Menu Reviews Tube feeding
Cancer (oncology) Gastrointestinal disorders Metabolic disorders Vegan nutrition
Coeliac Disease (Gluten Free) HIV Nursing home consultant Vegetarian nutrition
Communication/Marketing Healthy Eating Advice Osteoporosis Weight Loss
Community Education Heart Disease Paediatrics Women’s Health
Cooking classes/demos Infant feeding Polycystic Ovarian Syndrome
Diabetes Type I Kidney disease Pre-diabetes

Physiotherapists:
Acupuncture/Dry needling Hydrotherapy Parkinson’s Disease
Aged care Joint Stiffness Pelvic Floor
Amputations Lymphedema Pilates
Arthritis Massage Pregnancy
Back pain Mobility Parkinson’s Disease
Bursitis Movement Rheumatoid Arthritis
Cancer Multiple Sclerosis Spinal Dysfunction
Cardiorespiratory Musculoskeletal Sports Injuries
Child/Infant development Neurology Strains and sprains
Continence Occupational health Strength Training
Depression Orthopaedic Stroke
Diabetes Paediatric Women’s Health
Flexibility Pain management

Exercise Physiologists:
Acute pain management Exercise Stress Test Obesity
Aged Care Fitness Osteoarthritis
Asthma Flexibility Osteoporosis
Blood glucose management Health education Parkinson’s Disease
Cancer Heart Disease Population Health
Cerebral Palsy Hypertension Pregnancy
Cholesterol management Mental Health Rehabilitation
Chronic Heart Failure Metabolic Disease Rheumatoid Arthritis
Chronic Pain management Mobility Spinal cord injury
COPD Movement Sport
Cystic Fibrosis Multiple Sclerosis Strength Training
Diabetes Management Musculoskeletal Injury Stroke
Dyslipidaemia Musculoskeletal Pain Workplace Health