Healthy Outcomes Paediatric Program for Scarborough | Phone: 647-461-7030 | Fax: 416-284-3168 | HOPPS@rougevalley.ca Central Booking Office: Galaxy 12 Child & Teen Clinic, Scarborough and Rouge Hospital – Centenary Site,

2867 Ellesmere Road, Scarborough, ON, M1E 4B9

www.rougevalley.ca/hopps | www.tsh.to/hopps

Healthy Outcomes Paediatric Program for Scarborough (HOPPS) Patient Referral Form

Building Better Bodies Program (7–17yrs) Family Centred Counselling (2–6yrs)

Patient Information Date: Last name: First name:

DOB: Age: Sex: Health card number:

Address:

City: Province: Postal code:

Parent/guardian: Phone number: Cell number:

Physical Exam Weight (kg): Height (cm): BMI: %ile: BP:

** Please attach growth data (growth charts) AND the following investigations **

Fasting glucose CBC ALP T4 HgbA1C Ferritin ALT TSH Lipid profile (non-fasting) Urine analysis

Medical Comorbidities

GERD Hypertension Dyslipidemia Pre-diabetes PCOS Asthma NAFLD Type II diabetes Sleep apnea Orthopedic problem Microalbuminuria Acanthosis Nigricans

Current medications:

** Please fax completed referral to 416-284-3168 ** Incomplete referrals will not be processed

Referring physician (please print): Signature:

Physician number: Phone number: Fax number:

dd / mm / yy  

dd / mm / yy  

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