Medical Clearance Form - Adult

    At Centre for Integrative Health (CFIH), we take seriously the risks associated with eating disorders. In our efforts to ensure the health and safety of all patients visiting our clinic, we require the form below to be completed before completing an initial assessment. 

    If your patient is aged under 18 years, please complete the Medical Clearance Form for Children instead.

    If you suspect that your patient has an eating disorder and may also be eligible for an Eating Disorder Management Plan (EDMP), you are welcome instead to complete our GP Referral Form which serves as a CFIH referral form, CFIH medical clearance form, and  Eating Disorder Management Plan (EDMP) if eligible. 


    Referrer's Details

    A completed version of this form will be sent to this email address.

    Client Information

    Physical Examination

    If systolic pressure <80mmHg consider medical admission.
    Allow 1-2 minutes between lying and standing blood pressure measurements to ensure accuracy. If systolic pressure <80mmHg or orthostatic changes >20mmHg, consider medical admission.
    If resting pulse <50 bpm, consider medical admission.
    Allow 1-2 minutes between lying and standing pulse measurements to ensure accuracy. If orthostatic changes in pulse >20mmbpm, consider medical admission.

    Medical Investigations

    If serum potassium <3.2mmol/L, serum Chloride <88mmol/L, or hypoglycaemia noted, consider medical admission.

    If any arrhythmia present on ECG or prolonged QTc interval >450msec, consider medical admission.

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