Get started! Complete this form to get started. 1Client details2Part A: Important information3Part B: GP Referral Recommendations Client detailsName(Required) First Last Date of birth(Required) Day Month Year Phone(Required)Gender(Required) Email(Required) Date(Required) Day Month Year Signature(Required) Important information Please answer YES or NO to each question truthfully. If you answer YES to any questions in Part A, you are outside of my scope of practice, and I cannot support you at this time. I recommend you seek a referral to a Dietitian for support. If you answer YES to any questions in Part B, you will need to see a General Practitioner (GP) for a more detailed assessment and gain medical clearance before working with me. Part A: Client ExclusionsAre you pregnant or breastfeeding?(Required) Yes No Are you under the age of 16 years old (0-15 years old)?(Required) Yes No Have you been medically diagnosed with any eating disorder (i.e., anorexia nervosa, anorexia bulimia, binge eating disorder)?(Required) Yes No Have you been diagnosed with diabetes mellitus (i.e., pre-diabetes, type l, type Il & gestational diabetes)?(Required) Yes No Have you been diagnosed with coeliac disease?(Required) Yes No Do you have a current diagnosis of cancer and/or receiving treatment for cancer?(Required) Yes No Have you been diagnosed with renal disease?(Required) Yes No Have you ever had bariatric surgery (i.e gastric sleeve, gastric bypass, lap-band)?(Required) Yes No Have you been diagnosed with any of the following gastrointestinal tract issues? Diverticulitis, bowel obstructions and bowel resections, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) including ulcerative colitis and/or Crohn's disease.(Required) Yes No Have you been diagnosed with thyroid disease (i.e., hypothyroidism or hyperthyroidism)?(Required) Yes No Are you currently taking any prescribed medication for blood pressure, cardiovascular disease or high cholesterol, such as ACE inhibitors, beta blockers, warfarin or statins?(Required) Yes No Thank you for your interest in the Afterglow Program. Unfortunately, at this time, you are considered outside of my scope of practice, based on the information you provided in Part A. I recommend you see your GP for a referral to an Accredited Practising Dietitian to seek support. Should you need guidance or have any questions, please do not hesitate to reach out via the form below. Best wishes, Amanda Part B: GP Referral RecommendationsIs your BMI below 18.5kg/m2 (<18.5) or above 40kg/m2 (>40)? BMI = kg/m2 = Weight + (height x height).(Required) Yes No Have you been diagnosed with any conditions impacting fertility (i.e., polycystic ovarian syndrome, endometriosis)?(Required) Yes No Have you been formally diagnosed with any food allergies and/or intolerances?(Required) Yes No Have you been formally diagnosed with a mental health condition in which you are required to take medication?(Required) Yes No Based on the information you provided in Part B, you will need to see a General Practitioner (GP) for a more detailed assessment and gain medical clearance before working with me.NameThis field is for validation purposes and should be left unchanged.
