Patient Details

Referrer Details

Ongoing Treating GP's Details

Please provide the details of the participant's external ongoing treating GP

Medical Assessor's Details

Please provide the details of the medical professional who will perform the medical assessment  (they will be sent the next part of this form to complete). This may be the same professional as the above question.

Butterfly Next Steps Outpatient Program

Medical Assessment

Thank you for performing this medical assessment for your patient. 

Patients are required to be medically stable to access Next Steps and need to provide evidence of medical stability at referral stage, prior to commencing the program, and at every 4 weeks thereafter or as indicated/at the request of the Next Steps team. 

Butterfly Foundation does not provide medical monitoring and depends on the assessment of the referring medical practitioner to determine medical stability. All pathology (FBC, EUC, CMP, LFT, TFT, Random glucose) and ECG must be taken within the last 14 days of referral and should be uploaded via this form. You MUST upload the discharge summary, ECG, and blood test results, in addition to filling out the boxes on this form.

If results from medical tests are outside normal limits, we require a case consult with the treating GP to discuss risk to client and management plan. Where a patient becomes medically unstable while on our program, we will work with the GP to identify a more appropriate level of care.

Advice from the Guidelines for the Inpatient Management of Adult Eating Disorders in General and Psychiatric Settings in NSW (2014), stages that "a person with an eating disorder may be acutely medically compromised without necessarily presenting as underweight." 

The image below is a guide to medical instability from the Guidelines forementioned, distributed by the NSW Ministry of Health. 

I have completed a thorough medical assessment of,

and confirm that all tested medical parameters (as indicated above) are within normal limits and the patient is deemed to be medically stable at the time of assessment. If the patient is accepted into the Next Steps program, I agree to provide ongoing medical management. If the patient's results from medical tests fall outside of normal limits at any stage within the duration of the program, I will advise the Butterfly Team of this and participate in a case conference to review their ongoing suitability for the program.