Nutrition Solutions
Nutrition Solutions is a specialist nutrition and dietetic clinic for digestive health and gastrointestinal disorders. All appointments are with Jocelyn Hunter Clarke Dietitian (APD) & Nutritionist (AN).
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Coeliac disease
The low FODMAP diet
Food intolerance
Lactose intolerance
Irritable bowel syndrome
Inflammatory bowel disease
Diverticular disease
Crohn’s Disease
Ulcerative Colitis
Constipation
Gut health
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About Jocelyn
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Pre-consultation
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Pre-consultation
Thank you for booking an appointment at Nutrition Solutions. The consultation will last approximately 50-60 minutes and it is important that you arrive on time.
If you are unable to make your appointment, please let us know as soon as possible. This will allow us to arrange another time for you.
Please complete the pre-consult form below before your appointment. If you have any difficulty completing the form, please
contact us
so we can send you a form that you may print and complete what you can and bring it with you to your appointment.
Who is this appointment for?
Is this appointment for a child?
*
Yes
No
Basic details
Parent/Guardian name
*
First
Last
Child's name
*
First
Last
Child's date of birth
*
DD slash MM slash YYYY
Doctor information
Referring Doctor
Usual GP
Your basic details
Name
*
First
Last
Doctor information
Referring Doctor
Usual GP
Date of birth
DD slash MM slash YYYY
Age
Are you a...
Student
Pensioner
Do you have an EPC or GP Management Plan (GPMP) from your GP?
Please choose
Yes
No
Please note, we do not bulk bill. A Medicare Rebate of $52.95 applies if you have an EPC or GPMP
Reason for appointment
*
Gastrointestinal (gut) issues or Food intolerance
Other
Reason for child's appointment
*
Weight management issues
Fussy eating issues
Suspected Food Intolerance
Other
Please provide a brief description of the reason for appointment
*
About your child
Has your child ever been diagnosed with any of the following?
Attention Deficit Disorder (ADHD, ADD)
Oppositional Defiance Disorder (ODD)
Pervasive Developmental Disorder (PDD)
Autistic Spectrum Disorder (Asperger’s Syndrome, ASD)
Other
If you selected 'other' above, please provide details here
*
Early feeding history
Was your child breast fed?
*
Yes
No
If yes, how long for?
*
Was your child bottle fed?
*
Yes
No
Which formula was used?
*
And how long for?
*
Did your child have any feeding problems or problems with introduction of cow’s milk or solid foods?
*
Yes
No
If you answered 'yes' above, please explain the problems
*
Allergies and intolerances
Does your child suffer from any of the following?
Please check any that apply or move onto the next question
Eczema, hives, skin rashes
Swelling of lips, tongue, throat
Anaphylaxis, allergy
Asthma, wheeze, chronic cough
Sinus, hay fever, sneezing
Recurrent mouth ulcers
Migraines, headaches
Irritability, moodiness, restlessness, hyperactivity
Poor concentration, poor co-ordination, clumsiness
Joint pain, muscle pain
Sensitivity to perfumes, cleaning agents, petrol etc
Other
If you selected 'other' above, please provide
*
Reason for appointment
A brief description of your symptoms
*
About you
Are you currently taking any medication?
Yes
No
Please list any medications you are currently taking
*
Are you currently taking any vitamins or supplements?
Yes
No
Please list any vitamins or supplements you are currently taking
*
Have you identified any foods that cause or worsen your symptoms?
Yes
No
Please list any foods you have already identified that cause or worsen your symptoms
*
Do you have any allergies or intolerances?
Yes
No
Please explain and include any results of allergy or intolerlance testing
*
Previous medical history
Have you ever been diagnosed with any of the following?
Please check any that apply or move onto the next question
Irritable Bowel Syndrome
Coeliac Disease
Ulcerative Colitis
Crohn’s Disease
Barrett’s Oesophagus
Gastro-oesophageal Reflux Disease (GORD)
Other
If you selected 'other' above, please provide details here
*
Have you had any of the following procedures?
Please check any that apply or move onto the next question
Colonoscopy
Endoscopy
Screening Blood test for Coeliac Disease
Other tests
If you selected 'other' above, please provide details here
*
Current symptoms
Current symptoms
Please check any that apply or move onto the next question
Erratic bowel habits (combination constipation/diarrhoea)
Constipation
Diarrhoea
Abdominal pain/discomfort
Bloating (feeling of fullness)
Distension (abdomen increases in size)
Excess flatulence (gas)
Reflux, heartburn
Nausea/Vomiting
Other
If you selected 'other' above, please provide details here
*
Do you suffer from any of the following?
Please check any that apply or move onto the next question
Eczema, hives, skin rashes
Swelling of lips, tongue, throat
Anaphylaxis, allergy
Asthma, wheeze, chronic cough
Sinus, hay fever, sneezing
Recurrent mouth ulcers
Migraines, headaches
Irritability, moodiness, restlessness, hyperactivity
Poor concentration, poor co-ordination, clumsiness
Joint pain, muscle pain
Sensitivity to perfumes, cleaning agents, petrol etc
Other
If you selected 'other' above, please provide details here
*
Family history
Do any members of your family suffer from the following?
Please check any that apply or click submit to complete this form
Eczema, hives, skin rashes
Swelling of lips, tongue, throat
Anaphylaxis, allergy
Asthma, wheeze, chronic cough
Sinus, hay fever, sneezing
Recurrent mouth ulcers
Migraines, headaches
Irritability, moodiness, restlessness, hyperactivity
Poor concentration, poor co-ordination, clumsiness
Joint pain, muscle pain
Sensitivity to perfumes, cleaning agents, petrol etc
Other
If you selected 'other' above, please provide details here
*
Weight & Diet History
Your child’s current weight and height
*
Current weight
Current height
Are then any concerns about your child’s growth rate?
*
Yes
No
As you answered 'yes' to the above, please provide details
*
Weight and height
*
What is your current weight?
What is your height?
Is your weight stable?
*
Yes
No
Please provide details of any recent weight loss or gain?
*
Typical food intake
Please complete the following to provide information on a typical day's food intake
Breakfast
*
Morning tea
Lunch
*
Afternoon tea
Dinner
*
Typical snacks
If you drink coffee, how many per day?
If you drink alcohol, what and how often?
Please list any drinks you have throughout the day including water
Ready to submit!
Do you wish to be emailed a copy of this form?
Yes please
No thanks
Please enter your email address
*
Enter Email
Confirm Email
Δ
Thank you for booking an appointment at Nutrition Solutions. The consultation will last approximately 50-60 minutes and it is important that you arrive on time.
If you are unable to make your appointment, please let us know as soon as possible. This will allow us to arrange another time for you.
Please complete the pre-consult form below before your appointment. If you have any difficulty completing the form, please
contact us
so we can send you a form that you may print and complete what you can and bring it with you to your appointment.
Who is this appointment for?
Is this appointment for a child?
*
Yes
No
Basic details
Parent/Guardian name
*
First
Last
Child's name
*
First
Last
Child's date of birth
*
DD slash MM slash YYYY
Doctor information
Referring Doctor
Usual GP
Your basic details
Name
*
First
Last
Doctor information
Referring Doctor
Usual GP
Date of birth
DD slash MM slash YYYY
Age
Are you a...
Student
Pensioner
Do you have an EPC or GP Management Plan (GPMP) from your GP?
Please choose
Yes
No
Please note, we do not bulk bill. A Medicare Rebate of $52.95 applies if you have an EPC or GPMP
Reason for appointment
*
Gastrointestinal (gut) issues or Food intolerance
Other
Reason for child's appointment
*
Weight management issues
Fussy eating issues
Suspected Food Intolerance
Other
Please provide a brief description of the reason for appointment
*
About your child
Has your child ever been diagnosed with any of the following?
Attention Deficit Disorder (ADHD, ADD)
Oppositional Defiance Disorder (ODD)
Pervasive Developmental Disorder (PDD)
Autistic Spectrum Disorder (Asperger’s Syndrome, ASD)
Other
If you selected 'other' above, please provide details here
*
Early feeding history
Was your child breast fed?
*
Yes
No
If yes, how long for?
*
Was your child bottle fed?
*
Yes
No
Which formula was used?
*
And how long for?
*
Did your child have any feeding problems or problems with introduction of cow’s milk or solid foods?
*
Yes
No
If you answered 'yes' above, please explain the problems
*
Allergies and intolerances
Does your child suffer from any of the following?
Please check any that apply or move onto the next question
Eczema, hives, skin rashes
Swelling of lips, tongue, throat
Anaphylaxis, allergy
Asthma, wheeze, chronic cough
Sinus, hay fever, sneezing
Recurrent mouth ulcers
Migraines, headaches
Irritability, moodiness, restlessness, hyperactivity
Poor concentration, poor co-ordination, clumsiness
Joint pain, muscle pain
Sensitivity to perfumes, cleaning agents, petrol etc
Other
If you selected 'other' above, please provide
*
Reason for appointment
A brief description of your symptoms
*
About you
Are you currently taking any medication?
Yes
No
Please list any medications you are currently taking
*
Are you currently taking any vitamins or supplements?
Yes
No
Please list any vitamins or supplements you are currently taking
*
Have you identified any foods that cause or worsen your symptoms?
Yes
No
Please list any foods you have already identified that cause or worsen your symptoms
*
Do you have any allergies or intolerances?
Yes
No
Please explain and include any results of allergy or intolerlance testing
*
Previous medical history
Have you ever been diagnosed with any of the following?
Please check any that apply or move onto the next question
Irritable Bowel Syndrome
Coeliac Disease
Ulcerative Colitis
Crohn’s Disease
Barrett’s Oesophagus
Gastro-oesophageal Reflux Disease (GORD)
Other
If you selected 'other' above, please provide details here
*
Have you had any of the following procedures?
Please check any that apply or move onto the next question
Colonoscopy
Endoscopy
Screening Blood test for Coeliac Disease
Other tests
If you selected 'other' above, please provide details here
*
Current symptoms
Current symptoms
Please check any that apply or move onto the next question
Erratic bowel habits (combination constipation/diarrhoea)
Constipation
Diarrhoea
Abdominal pain/discomfort
Bloating (feeling of fullness)
Distension (abdomen increases in size)
Excess flatulence (gas)
Reflux, heartburn
Nausea/Vomiting
Other
If you selected 'other' above, please provide details here
*
Do you suffer from any of the following?
Please check any that apply or move onto the next question
Eczema, hives, skin rashes
Swelling of lips, tongue, throat
Anaphylaxis, allergy
Asthma, wheeze, chronic cough
Sinus, hay fever, sneezing
Recurrent mouth ulcers
Migraines, headaches
Irritability, moodiness, restlessness, hyperactivity
Poor concentration, poor co-ordination, clumsiness
Joint pain, muscle pain
Sensitivity to perfumes, cleaning agents, petrol etc
Other
If you selected 'other' above, please provide details here
*
Family history
Do any members of your family suffer from the following?
Please check any that apply or click submit to complete this form
Eczema, hives, skin rashes
Swelling of lips, tongue, throat
Anaphylaxis, allergy
Asthma, wheeze, chronic cough
Sinus, hay fever, sneezing
Recurrent mouth ulcers
Migraines, headaches
Irritability, moodiness, restlessness, hyperactivity
Poor concentration, poor co-ordination, clumsiness
Joint pain, muscle pain
Sensitivity to perfumes, cleaning agents, petrol etc
Other
If you selected 'other' above, please provide details here
*
Weight & Diet History
Your child’s current weight and height
*
Current weight
Current height
Are then any concerns about your child’s growth rate?
*
Yes
No
As you answered 'yes' to the above, please provide details
*
Weight and height
*
What is your current weight?
What is your height?
Is your weight stable?
*
Yes
No
Please provide details of any recent weight loss or gain?
*
Typical food intake
Please complete the following to provide information on a typical day's food intake
Breakfast
*
Morning tea
Lunch
*
Afternoon tea
Dinner
*
Typical snacks
If you drink coffee, how many per day?
If you drink alcohol, what and how often?
Please list any drinks you have throughout the day including water
Ready to submit!
Do you wish to be emailed a copy of this form?
Yes please
No thanks
Please enter your email address
*
Enter Email
Confirm Email
Δ
Nutrition Solutions PO Box 3197 Yeronga 4104
Call us 07 3051 5833
Fax us 07 3051 0476
Book a consult
Email us
info@nutrition-solutions.com.au