Pre-consultation administration

The following information is gathered from you as the patient for the dietitian to send you medical aid statements, save time during your first consultation and provide you care during your treatment.

1Consent

2Personal Details

3Confirm Details

4Medical Background

5Food Background

Name(Required)

First Last

Consent to the following:(Required)

I consent

The information provided is correct, honest and comprehensive.
I understand that the practitioner cannot be held responsible for incomplete or inadequate information provided by me (diagnosis, medical history, allergies, billing information, contact details).
I understand that the medical scheme and main member of the medical scheme will be aware of the diagnosis and treatment of myself, as it is stated on the invoice/statement.
I give permission to the practitioner to share information with my doctor or allied medical professional if necessary. I understand that I will be given notice before sharing any personal information or any kind.
Selective personal information may also be requested during specific circumstances such as a practice or medical aid audit or medical or legal case. I give permission to the practitioner to provide personal information in such case. I understand that I will be given notice before sharing any personal information or any kind.
I agree to pay for my consultation beforehand. I understand that I am liable for the total cost of consults and that the practitioner cannot guarantee reimbursement from the medical scheme.
I understand that Dietitian tariffs are calculated using the face-to-face contact time consults as well as the time used to develop meal plans and educational material.
I understand that it is my responsibility to schedule, reschedule or cancel follow-up consultations if I am no longer able to attend 24 hours or more prior to my consultation.
I agree to be on time or notify the practitioner of any delay prior to the consultation.
I understand that statements, invoices and other important documents will be emailed to me, and it is my responsibility to handle these documents securely once emailed.
I understand that results are not guaranteed. Progress and adherence to the plans are my responsibility.
I understand that physical measurements may be required during consultations. Verbal consent will be attained before any measurements are done.
I agree to be added to the Dish Up Dietitians MailerLite email support program to enhance my results.
I agree to be added to the Dish Up Dietitian’s VitaScript profile in order to get tailored supplement prescriptions as part of my meal plan.
I agree that my medical information and progress may be used anonymously by Dish Up Dietitians at journal club presentations where practitioners upskill and learn from each other’s cases.
I agree that my information can be securely shared with all members of the Dish Up Dietitians team.
I agree to the terms and conditions in Dish Up Dietitian’s POPIA Manual and Privacy Notice.

For more guidance on how Dish Up Dietitians will manage your data, please click here for our POPIA Manual and Privacy Notice.

Willow Worx Newsletter

I consent

I agree to be added to the monthly newsletter sent out by Willow Worx Health Centre which is one of Dish Up Dietitian’s practice venue.

Form of Identification(Required)

SA ID Number

Birth date of minor

ID Number(Required)

Birth Date of Minor(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Postal Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Medical Aid Name

Medical Aid plan

Medical Aid Number

Main Member Full Name

Main Member ID Number

Please review and confirm your details are correct before proceeding.

Field	Value
Name (First):	{Name (First):1.3}
Name (Last):	{Name (Last):1.6}
Form of Identification:	{Form of Identification:7}
ID Number:	{ID Number:6}
Birth Date of Minor:	{Birth Date of Minor:9}
Gender:	{Gender:34}
Postal Address (Street Address):	{Postal Address (Street Address):10.1}
Postal Address (Address Line 2):	{Postal Address (Address Line 2):10.2}
Postal Address (City):	{Postal Address (City):10.3}
Postal Address (ZIP / Postal Code):	{Postal Address (ZIP / Postal Code):10.5}
Postal Address (Country):	{Postal Address (Country):10.6}
Phone:	{Phone:11}
Email:	{Email:12}
Medical Aid Name:	{Medical Aid Name:13}
Medical Aid Plan:	{Medical Aid plan:14}
Medical Aid Number:	{Medical Aid Number:15}
Medical Aid Main Member:	{Main Member Full Name:16}
Medical Aid Main Member ID Number:	{Main Member ID Number:17}

You are welcome to review your details by navigating back using the 'Previous' button below

My Details Are Correct(Required)

I confirm

Medical Background

Who referred you to us?

What is the reason you want to see us?

Have you seen a dietitian before?(Required)

Yes

When was the last time you had blood tests done at a Lancet or Ampath labs?

Please list your medication and the reason for taking it(Required)

Please list the supplements you take(Required)

Do you experience any of these medical conditions?(Required)

Food allergies/intolerances

Headaches/migraines

Reflux/heartburn

Irregular blood sugar levels

Diabetes

High blood pressure

Heart problems

High cholesterol

Stroke

Stomach cramping

Bloating

Constipation

Diarrhoea

Pain or blood when passing a stool

Low or high iron levels

Low vitamin D levels

Osteoporosis (low bone density)

Arthritis (swollen stiff joints)

Gout

Thyroid dysfunction

Cancer

Stomach ulcers

Eating disorder

None of the above

Do you experience any of these medical conditions (female specific)?(Required)

Irregular periods

Heavy periods

Severe PMS

Fibrous breast tissue

Polycystic ovarian syndrome

Endometriosis

Fibroids

Hemorrhoids/piles

Unusual hair growth (moustache, stomach, sideburns, nipple etc)

Any complications in pregnancies

Miscarriages

Infertility

None of the above

Are you a smoker?(Required)

Yes

Did your parents/grandparents have any of the following conditions?

Cancer

Diabetes

High blood pressure

Heart problems

High cholesterol

Stroke

Osteoporosis

Arthritis

Gout

Poor mental health

Is there any extra information you would like the dietitian to know before the consult?

Food Background

Please select the foods/drinks you do consume(Required)

Beef

Pork

Poultry/chicken

Lamb

Fish

Salmon

Trout

Sardines

Pilchards

Mackerel

Lentils

Chickpeas

Beans (eg baked, butter, kidney etc)

Alcohol

Water

Fruit juice

Fizzy colddrinks/sodas

Milk

What alcohol do you consume?(Required)

How many drinks do you have a week?(Required)

How many glasses of water do you drink per day?(Required)

What type of milk do you choose?(Required)

Do you have any religious food restrictions or food allergies?(Required)

Are there any foods you don’t like or eat?(Required)

What are your favourite foods?(Required)

Do you ever skip meals?(Required)

Please provide examples of foods you may have at the following mealtimes:

Breakfast(Required)

Post-breakfast snack(Required)

Lunch(Required)

Post-lunch snack(Required)

Dinner(Required)

Post-dinner snack(Required)