Patient Referral Form

To: A Better Way Health Center Medical Staff

From:

__________________________________________________________(Physician Name) __________________________________________________________(Clinic) __________________________________________________________(Street) __________________________________________________________(City, State, Zip) __________________________________________________________(Phone, Email address) ________________________________________________________________, (Patient Name) a patient under my care as his/her________________________________________________________, (e.g., Primary Care Provider, Internist, Cardiologist, Obstetrician-Gynecologist) is being referred by me to A Better Way Health Center's Weight Management Program for evaluation and treatment. I have discussed with this patient the health implications of his/her current overweight condition, and we both concur that behavioral attempts to improve this condition have produced less than satisfactory results to date. I understand that A Better Way Health Center¹s medical staff will evaluate this patient for program eligibility, with referral back to his/her primary care provider should either a previously undisclosed medical condition be detected or further workup be deemed prudent. I also understand that A Better Way Health Center's program emphasizes long-term weight management, incorporating instruction in proper nutrition and appropriate exercise, behavioral guidance, and at the discretion of both the Center's medical staff and the patient, the use of the appetite suppressant, phentermine, if not medically contraindicated. Checked below are the weight-related risk factors or medical conditions which apply to this patient. If the patient¹s Body Mass Index (BMI) is under 27.0 kg/m2, I have elaborated on the patient¹s risk(s) or condition(s) which could benefit from even modest weight loss. A separate page is attached, if necessary. BMI = (Weight (lbs) / (Height (inches))2 ) * 704.5 >=30___ 27.0-29.9___ 25.0-26.9___ <25.0___ Risk Factors (Family History/Laboratory) Medical Conditions ___Type 2 Diabetes ___Hypercholesterolemia ___Type 2 Diabetes ___Sleep Apnea ___CHD ___Elevated LDL/HDL ratio ___CHD ___Osteoarthritis ___Stroke ___Decreased Glucose Tolerance ___Angina (stable) ___Gallstones ___Breast CA ___Waist Circumference ___Peripheral ___Hypertension ___Colon CA (Men >40²; Women >35²) Vascular Disease (medication-controlled) ___Endometrial or Prostate CA ___Other________________________________________

Dietary Considerations (e.g., food allergies, special nutritional requirements)_______________________ ___________________________________________________________________________________

Physical Activity Restrictions____________________________________________________________ ___________________________________________________________________________________

Special Considerations_________________________________________________________________ ___________________________________________________________________________________

_________________________________________________________________________ (Signature)

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