Child's Full Name

Date of Birth

Age (8 - 17)

Gender
MaleFemale

Heightcmin

Weightlbskg

BMI (if known)lbs/in²kg/m²

Name of Parent/Guardian

Contact Phone Number

Parent Contact Email

Address

Type 2 DiabetesPre-diabetesHigh blood pressureHigh cholesterolAsthmaObstructive sleep apneaJoint pain or orthopaedic issuesMental health concernsOther

If Mental health concerns, please specify here:

If Other, please specify here:

Medications

General weight management supportNutrition counsellingPhysical activity guidanceOther

If Other, please specify here:

Additional Notes

Referring Doctor's Name / Signature

Doctor's Email Address