Patient Information

Help us prepare for your consultation! Please allow yourself 10-15 minutes to complete this form in as much detail as possible.

Personal Details

Lifestyle

Home

Work

Physical Activity

Other

Medical

Blood Tests

Clinical

Dietary

General

Eating Habits

0 days
0 days
0 grams
0 pieces

Drinking

0 mL
0 cups
0 mL
0 litres

Daily Intake

Please outline your usual day's intake, with alternatives. Eg, breakfast: 1 large bowl of cornflakes + trim milk + 1 tsp sugar OR 2 fried eggs + 3 rashers bacon on weekends. Please record as much detail as possible.

Important Information

Health Care Consent

Privacy Information & Consent

The main reason we collect information from you is so that we can provide the best nutrition advice based on your health needs. We will use the information you provide in the following ways:

  • Administration purposes in running Dietcare Mackay.
  • Billing, including compliance with your health insurance.
  • Disclosure to others involved in your health care, including your current GP or doctor outside this practice who may be involved in treating you. This may occur if we need to refer you back to him/her for further medical related tests.
  • For research and quality assurance activities to improve individual, community health care and practise management.
  • Disclosure to others for medical defence or legal purposes, if necessary.

We are committed to protecting the confidentiality of your record. The privacy of your information is also protected by law. We treat your information on the strictest confidence and store it securely.