IC Doctor Letter
Created by
Kim Nguyen
Specialty
Dietitian
Last edited
10/20/2026
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0 times
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About this template
A reusable dietitian letter structure for documenting a referral assessment, including the relevant condition, medical and social history, bowel habits, dietary intake, anthropometry, clinical impression, recommendations, and follow-up. It is designed to support clear communication of personalised dietary advice without adding information that was not explicitly provided.
Preview template
Thank you for referring Sarah, a 34-year-old female, for assessment of Irritable Bowel Syndrome (IBS-D).
Sarah reports a 2-year history of abdominal cramping, bloating, and erratic bowel habits, exacerbated by work stress. She is highly motivated to identify dietary triggers to improve her daily quality of life.
PMHx: Endometriosis (laparoscopy 2021), mild anxiety. Investigations: Coeliac serology negative (12/03/2024), faecal calprotectin 18 µg/g (12/03/2024), routine FBC/iron studies NAD.
Lives with partner, works FT as an accountant. Non-smoker, EtOH 2-3 std drinks/week. Exercises 3x/week (Pilates).
BO 3-4x/day, typically Bristol Stool Chart Type 6, associated with urgency and post-prandial bloating. No PR bleeding or nocturnal symptoms.
Medications: Escitalopram 10 mg PO mane, mebeverine 135 mg PO PRN, Inner Health Plus probiotic 1 cap PO daily.
Assessment
24-hour recall indicates irregular meal timings due to workload. Breakfast: Sourdough toast with avocado and coffee. Lunch: Chicken and salad wrap or leftovers. Dinner: Stir-fry with beef/chicken, mixed vegetables, and rice. Snacks: Apples, almonds, protein bars. High fluid intake (2.5 L water/day + 2x flat whites). Financially secure with good access to fresh produce.
Adequate representation of lean meats and grains. Suboptimal intake of low-FODMAP fruit and vegetables; high reliance on wheat-based products and lactose-containing dairy.
High intake of fructans (garlic, onion, wheat) and excess fructose/polyols (apples, stone fruit, protein bars sweetened with sorbitol) correlating strongly with afternoon bloating and urgency.
Recently trialled a self-directed dairy-free diet for 2 weeks with minimal symptom resolution.
Reports high work-related stress (7/10), which directly precipitates gut symptoms.
Anthropometry
Weight: 64.2 kg, Height: 168 cm, BMI: 22.7 kg/m².
Weight stable over the past 12 months. No unintentional weight loss.
IBS-D likely exacerbated by high intake of fermentable carbohydrates (specifically fructans, lactose, and polyols), irregular meal patterns, and visceral hypersensitivity secondary to stress.
Commence Phase 1 (elimination) of the Low FODMAP diet for 4 weeks, focusing on garlic/onion alternatives, lactose-free dairy, and swapping high-FODMAP snacks. Provided Monash FODMAP app education and meal-spacing strategies.
Review scheduled in 4 weeks to assess symptom resolution and guide Phase 2 (reintroduction) challenges.
"Thank you again for the referral; I look forward to supporting Sarah with the management of Irritable Bowel Syndrome (IBS-D)."
"Kind regards,
Accredited Practicing Dietitian"
cc: Dr. Marcus Vance (Gastroenterologist)
How to use this template
This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.