Weight Management Center. Medical Nutrition Therapy and Diabetes Education. Referral Form Diabetes Education. Please check all that apply. Newly Diagnosed …
Weight Management Center
Medical Nutrition Therapy and Diabetes Education
Referral Form
Revised October 2005
To Schedule: 713 441- 5975 Fax: 713 790-6366
Thank you for your referral Please fill out the following information so
that we may service your patient We will contact your patient and schedule
them for the services you prescribe
Patient Name:
___________________________________________________________________________
Home Phone: ____________________________ Work Phone:
____________________________________
Physician Name: ________________________ Phone: __________________ Fax:
____________________
Physician Signature: _____________________________________ Date:
____________________________
|Primary Diagnosis |ICD 9 |Secondary Diagnosis |ICD 9 |
| | | | |
| | | | |
| | | | |
Diet Order: _________________________ If not completed, to
be determined
by RD based on diagnosis
Labs: Please attach recent pertinent labs, history, and physical, or
complete the following:
|Date | | |Date | | |Date | | |Date | | |Glucose | | |CHOL | | |TG | |
|Albumin | | | |HbA1c | | |HDL | | |BUN | | |Pre Albumin | | |
|Microalbuminuria | | |LDL | | |Creatinine | | |Phosphorus | | | |
Diabetes Education
Please check all that apply
o Newly Diagnosed
o Type 1
o Type 2
o Diet Controlled
o Orals Name: __________________ Dose: _________ Time: __________
o Insulin: _______________________ Units: __________ Time: __________
o Gestational - EDD: ______________
Please check all that apply for education purposes:
o Home Blood Glucose Monitor
o Diet Instruction
o Weight Loss
o Other: _______________________
Bariatrics
o Insurance Requirement
o Pre-surgery
o Post-surgery
Source:gov.mb.ca
