Generation Health Clinic Virtual English Program Referral Form Instructions

Enter the date when the referral form was signed (e.g. YYYY-MM-DD).

Enter the date when these anthropometric measurements were taken.

Enter the individual's height in centimeters.

Enter the individual's weight in kilograms.

Enter the calculated Body Mass Index.

Enter the individual's blood pressure reading.

Check this box if the family will travel to Nanaimo for a medical assessment by a Generation Health Clinic physician.

Check this box if the medical assessment will follow a Shared Care Model, with a comprehensive physical examination done by a referring physician or nurse practitioner in collaboration with a Generation Health Clinic physician.

Enter the child’s full name as it appears on official records.

Enter the child’s date of birth in day-month-year format (dd-mm-yy).

Enter the child’s Personal Health Number (PHN) issued by the provincial health authority.

Check this box if the child's sex is male.

Check this box if the child's sex is female.

Check this box if the child's sex is intersex.

Check this box if the child has insulin resistance, prediabetes, or diabetes. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has dyslipidemia. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has depression or anxiety. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has obstructive sleep apnea or other sleep-disordered breathing. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has metabolic associated fatty liver disease (formerly NAFLD). Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child is experiencing musculoskeletal pain. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has prehypertension or hypertension. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has polycystic ovary syndrome (PCOS). Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Check this box if the child has experienced weight-based bullying. Fill only if the 'BMI for age >85th %ile with or at high risk of developing comorbidities (see list below)' is Yes.

Provide a comprehensive overview of the family's medical history, including any relevant conditions, diseases, or genetic predispositions.

Check this box if the family is ready or interested in making healthy living changes.

Check this box if the family is not ready or interested in making healthy living changes.

Check this box if the parents/guardians are aware of the referral and have given consent to be referred and contacted by phone call, email, and/or text.

Check this box if the parents/guardians are not aware of the referral or have not given consent to be referred and contacted by phone call, email, and/or text.

Check this box if at least one parent or caregiver is able to speak, write, and understand English in a discussion-based group setting.

Check this box if no parent or caregiver is able to speak, write, and understand English in a discussion-based group setting.

Check this box if the child lives with both parents who are married or in a common-law relationship.

Check this box if the child is under the sole guardianship of one individual.

Check this box if the child is under the joint guardianship of two or more individuals.

Check this box if none of the other guardianship status options apply, and specify the status in the provided field.

Please provide details about the specific guardianship status. Fill only if 'Other' is 'Yes'.

Check this box if mental health or addiction concerns are significant stressors affecting the child or family's home environment.

Check this box if there are other significant home environment stressors not listed, and provide details in the adjacent description field. Fill only if 'Mental health/addictions concerns' is 'Yes'.

Check this box if family conflict is a significant stressor affecting the child or family's home environment.

Please describe the first additional significant stressor affecting the child or family's home environment. Fill only if 'Family conflict' is 'Yes'.

Check this box if food insecurity is a significant stressor affecting the child or family's home environment.

Please describe the second additional significant stressor affecting the child or family's home environment. Fill only if 'Food insecurity' is 'Yes'.

Check this box if the individual has neurodiversity, such as Autism Spectrum Disorder (ASD) or Attention-Deficit/Hyperactivity Disorder (ADHD).

Check this box if the individual has socio-emotional concerns.

Check this box if the individual exhibits behavioural problems.

Check this box if the individual has psychiatric concerns.

Check this box if there is a high-risk family history relevant to the individual's health.

Check this box if there are other concerns not listed above and provide a description in the space provided.

Please provide details for the first other concern not listed. Fill only if 'Other (please describe)' is 'Yes'.

Please provide details for the second other concern not listed. Fill only if 'Other (please describe)' is 'Yes'.

Please enter the full name of Parent/Guardian 1.

Please enter the full street address for Parent/Guardian 1.

Check this box if the primary phone number for Parent/Guardian 1 is a cell phone.

Check this box if the primary phone number for Parent/Guardian 1 is a home phone.

Please enter the primary phone number for Parent/Guardian 1.

Please enter an alternate phone number for Parent/Guardian 1.

Please enter the email address for Parent/Guardian 1.

Enter the full name of Parent or Guardian 2. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Provide the complete mailing address for Parent or Guardian 2. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Enter the primary phone number for Parent or Guardian 2. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Check this box if the primary phone number provided for Parent/Guardian 2 is a cell phone. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Check this box if the primary phone number provided for Parent/Guardian 2 is a home phone. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Enter an alternate phone number for Parent or Guardian 2. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Provide the email address for Parent or Guardian 2. Fill only if 'Lives with both parents/Married/Common Law', 'Joint Guardianship' is 'Yes' for any.

Provide a comprehensive description of the patient's past medical history, including any available consults, recent bloodwork, imaging, or diagnostic results.

Enter the full name of the primary care provider.

Enter the practitioner number for the primary care provider.

Enter the full mailing address for the primary care provider.

Enter the phone number for the primary care provider.

Enter the fax number for the primary care provider.

Provide any additional anthropometric measurements or related notes, such as growth chart percentiles or head circumference data.

Check this box if the patient's BMI for their age is greater than the 97th percentile.

Check this box if the patient's BMI for their age is greater than the 85th percentile, or if they are at high risk of developing comorbidities.

Please enter the date of the referral.

Please enter the full name of the referring practitioner.

Please enter the unique identification number for the referring practitioner.

Please enter the medical specialty of the referring practitioner.

Please enter the full mailing address of the referring practitioner.

Please enter the primary phone number of the referring practitioner.

Please enter the fax number of the referring practitioner.