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

Full Name *

Today's date *

Practice details

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

Client Information

First Name *

Last Name *

Date of Birth *

Age

Physical Examination

BP Lying (mm Hg) *If systolic pressure <80mmHg consider medical admission.

BP Standing (mm Hg) *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.

Systolic pressure has been indicated to be <80mmHg

Consider medical admission

Pulse Lying (bpm) *If resting pulse <50 bpm, consider medical admission.

Pulse Standing (bpm) *Allow 1-2 minutes between lying and standing pulse measurements to ensure accuracy. If orthostatic changes in pulse >20mmbpm, consider medical admission.

Resting pulse has been indicated to be <50bpm

Consider medical admission

Medical Investigations

FBC, eLFTs, Mg, Vit D, Iron Studies, B12 & Folate studies, Lipids, Urine Spec. Gravity, ECG *

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.

Upload investigation results here

Browse

Additional comments

The client does not currently meet medical admission criteria and is suitable for outpatient treatment
If the client meets any of the criteria for medical admission, we reccomend referring to the hospital emergency department to be assessed for consideration of a possible medical admission (as per the Queensland Health guidelines for the medical management of eating disorders). *

I agree to continue monitoring and managing this client medically whilst they are engaged in outpatient treatment *

GP Signature *

Draw signature|Type signatureClear

CAPTCHA *