N
utrition
I
nnovators, Inc.
Dorian Driscoll MS, LDN, RD
509 Rue De Belier
Lafayette LA 70506
337 654-9528 -- Fax 337 993-0234
nutritioninnovators@yahoo.com
www.nutritioninnovators.com
TRIM KIDS
TM
PHYSICIAN'S CLEARANCE FORM
_______________________________________________________ may enter the Trim
Kids
TM
weight management program.
_______________________________________________________ has not met the medical
requirements of screening to enter the Trim Kids
TM
weight management program.
Ht. _________ Wt. ________ BMI _________ Tanner Stage ____________________
Date of last visit: ____________________________________________________________
REFERRAL:
Pulmonary
Endocrinology
Orthopedics
Other
FOLLOW-UP VISIT
RECOMMENDED:
12 Weeks
6 Months
1 Year
Other
Physician's Signature: _____________________________________________________________
Date: _________________________________________
RETURN TO T
RIM KIDS
TM