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NUTRITIONAL ADVISOR/NRN RISK-STRATIFICATION

This risk-stratification screening tool does not substitute advice from an appropriately qualified Medical or Allied Health Professional. This risk-stratification screening tool does not promise or warrant against injury or death and no guarantee of protection should result from the use of this risk-stratification tool. No liability or responsibility in any shape or form can be accepted by Nutrition Council Australia (NCA), for any injury, loss, harm or damage that may emerge or become apparent from any person acting on the instruction of (or any statement or information) this risk-stratification screening tool.
CLIENT DETAILS
Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
CONTACT DETAILS
Gender(Required)

SECTION 1: IDENTIFY THE CLIENT'S CURRENT HEALTH STATUS

PART A IDENTIFY CURRENT MEDICAL CONDITIONS
PLEASE ANSWER YES OR NO
1. Are you pregnant or breastfeeding?(Required)
2. Are you under the age of 16 years old (0-15 years old)?(Required)
The following questions refer specifically to 'chronic health conditions' (an illness persisting for a long time or constantly recurring).
3. Have you been medically diagnosed with any eating disorder (i.e., anorexia nervosa, anorexia bulimia, binge eating disorder)?(Required)
If yes, please indicate below:
4. Have you been diagnosed with diabetes mellitus (i.e., pre-diabetes, type I, type II & gestational diabetes)?(Required)
If yes, please indicate below:
5. Have you been diagnosed with coeliac disease?(Required)
6. Have you been diagnosed with cancer?(Required)
7. Have you been diagnosed with renal disease?(Required)
8. Have you ever had bariatric surgery (i.e gastric sleeve, gastric bypass, lap-band)?(Required)
If yes, please indicate below:
9. Have you been diagnosed with any of the following gastrointestinal tract issues? Diverticulitis, bowel obstructions and bowel resections, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD) including ulcerative colitis and/or Crohn's disease.(Required)
If yes, please indicate below.
10. Have you been diagnosed with thyroid disease (i.e., hypothyroidism or hyperthyroidism)?(Required)
If yes, please indicate below.
11. Are you currently taking any prescribed medication for blood pressure, cardiovascular disease or high cholesterol, such as ACE inhibitors, beta blockers, warfarin or statins?(Required)
If yes, please list the medication(s) below and provide a reason for taking the medication(s):
PART B IDENTIFY 'AT RISK' FACTORS
PLEASE ANSWER YES OR NO to the following questions:
1. Is your BMI below 18.5kg/m2 (<18.5) or above 40kg/m2 (>40)? BMI = kg/m2 = Weight ± (height x height)(Required)
If yes, please indicate your BM/ below
2. Have you been diagnosed with any conditions impacting fertility (i.e., polycystic ovarian syndrome, endometriosis)?(Required)
If yes, please indicate below.
3. Have you been formally diagnosed with any food allergies and/or intolerances?(Required)
If yes, please specify food allergy, diagnostic tool and an approximate diagnosis date.
4. Have you been formally diagnosed with a mental health condition in which you are required to take medication?(Required)

SECTION 2: IDENTIFY POSSIBLE FOOD INTOLERANCES/ALLERGIES


PLEASE ANSWER YES OR NO to the following questions:
1. Do you experience bloating regularly(Required)
2. Do you believe you suffer from excessive flatulence?(Required)
3. Do you experience irregular bowel motions (i.e., diarrhoea, constipation, sore to pass, abnormal colours, faecal urgency)?(Required)
If yes, please provide details below on the number of eliminations per day, stool colour, stool abnormalities and stool formation where possible
4. Do you believe you suffer from low energy levels?(Required)
If yes, please provide more information below
5. Do you suspect you may have any food allergies and/or intolerances?(Required)
If yes, please identify why you think you may have an allergy/intolerance and to what specific food:

SECTION 3: IDENTIFY FAMILY HEALTH HISTORY


PLEASE ANSWER YES OR NO to the following questions:
1. Has an immediate family member (parents or siblings) ever been diagnosed with any of the chronic health conditions outlined in Section 1: A?(Required)
If yes, please list the medical condition(s) below:
2. If you have answered 'yes' to the above question, have you had a health check within the last 12 months and been cleared for that condition?(Required)
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