Hornsby Healthy Kids
	    Hornsby General Practice Unit
      3-7 Derby Road, Hornsby 2077

       Hornsby Ku-ring-gai Hospital
         Department of Paediatrics
        Phone 9477 9146 Fax 9477 9824

Fax completed form to 9477 9824
A multidisciplinary weight management service for overweight or obese children <12 years old and their families staffed by:
Paediatricians – Dr Anna Gill / Dr Kate Webster;  GP – Dr Jennifer Kendrick ; Exercise therapist –Tom Carruthers; Dieticians – Kerryn Chisolm and Caroline Hill; Clinical Psychologist – Beatrijs Dewulf; Registered Nurse Nicole Page; GP Registrar.

Patient details:
Surname:    <<Patient Demographics:Surname>>    Given name:    <<Patient Demographics:First Name>>	DOB:    <<Patient Demographics:DOB>>	Sex:    <<Patient Demographics:Sex>>
Parent/Carer Contact Details:    <<Head of Family:Full Name>>
Home phone:    <<Patient Demographics:Phone (Home)>>    Mobile phone:    <<Patient Demographics:Phone (Mobile)>>
Language spoken at home:    <<Patient Demographics:Language Spoken>>
Interpreter required:    <<Patient Demographics:Requires Interpreter>>   If Yes, specify language:    <<Patient Demographics:Language Preferred>>
Clinical details:
Weight:	    <<Weight>>    Height:    <<Height>>    BMI:    <<BMI>>    BMI centile:    <<BMI centile>>
(see reverse of this page for calculation and tables)
Go4Fun completion date if applicable:........................................
Investigations if already performed: - not needed routinely. Please attach results if applicable.
(Consider fasting BSL, Insulin, TG, Cholesterol +/- Vit D, iron studies, LFTs.)
 <<Summary:Investigation Results (Selected)>>
Other significant medical or social history:
<<Clinical Details:Family History>>

Patient Agreement
I, …………………………………............................(parent/guardian signature) have discussed the referral to Hornsby Healthy Kids with our doctor and consent to participate. I understand that participation in the clinic requires regular attendance and monitoring of progress and that measurements and progress will be recorded and used for ongoing evaluation of the clinic program.
Referring Doctor Details	
Name:    <<Doctor:Name>>	
Provider number:    <<Doctor:Provider Number>>
Address:    <<Doctor:Address>>
Phone:    <<Doctor:Phone>>		Fax:    <<Doctor:Fax>>

Signature    ..............................………………………………………             Date  <<Miscellaneous:Date>>
BMI centile charts taken from CDC Growth charts
Overweight is defined as 85th to 95th centile for age.       Obese is defined as over the 95th centile for age
BMI = weight in kg ÷ (Height in metres)2