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PHYSICIAN REFERRAL FORM For children and adolescents with obesity Please print clearly DATE Child's Name: Male or Female (last name) (first name) Child's Age: DOB: (YYY/mm/dd): PhD #: Parent/Guardians

How to fill out obesity referral form

How to fill out obesity referral form:

1. Start by entering your personal information, such as your name, date of birth, and contact details. This will help the healthcare provider identify and reach out to you if needed.
2. Provide details about your medical history, including any previous diagnoses or treatments related to obesity. It is important to be accurate and thorough in this section, as it will help the healthcare provider understand your background and tailor their recommendations accordingly.
3. Indicate any medications you are currently taking for obesity or any other medical conditions. This information is crucial for the healthcare provider to ensure that there are no potential interactions or contraindications with other medications.
4. Describe any symptoms or concerns you have related to obesity that prompted you to seek a referral. This can include issues such as difficulty losing weight, obesity-related health complications, or a desire for specialized care.
5. If applicable, provide details about any previous attempts you have made to manage or treat obesity, such as participating in weight loss programs, following specific diets, or engaging in regular exercise. This will give the healthcare provider insights into your previous efforts and help them develop a suitable plan moving forward.
6. Lastly, sign and date the form to confirm that the provided information is accurate and complete.

Who needs obesity referral form:

1. Individuals who are struggling with obesity and require specialized medical intervention should fill out an obesity referral form. This form is typically used to connect patients with healthcare professionals who have expertise in managing and treating obesity.
2. Healthcare providers may recommend filling out an obesity referral form for individuals who have a high body mass index (BMI) or are at risk of developing obesity-related health complications. This form enables them to assess the individual's condition more comprehensively and provide appropriate guidance and treatment options.
3. Individuals who have already tried lifestyle modifications, such as diet and exercise, but have not achieved significant weight loss or improvement in their health may benefit from submitting an obesity referral form. This helps healthcare providers understand their specific needs and develop a personalized treatment plan.

Note: It is essential to consult with a healthcare provider or follow the specific guidelines of the healthcare institution you are associated with when filling out an obesity referral form, as requirements may vary.

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What is obesity referral form?

Obesity referral form is a document used to refer individuals who are dealing with obesity to specialized healthcare providers for further evaluation and treatment.

Who is required to file obesity referral form?

Healthcare providers such as primary care physicians, dietitians, and other medical professionals are required to file obesity referral forms for their patients.

How to fill out obesity referral form?

To fill out an obesity referral form, healthcare providers need to provide patient information, medical history, current weight and height, and reasons for the referral.

What is the purpose of obesity referral form?

The purpose of obesity referral form is to ensure that individuals struggling with obesity receive appropriate care and treatment from specialized healthcare providers.

What information must be reported on obesity referral form?

Information such as patient demographics, medical history, current weight and height, and reasons for the referral must be reported on obesity referral form.