Green Prescription Lead Maternity Referral Form Personal Details First Name * : Last Name * : NHI * : Date of Birth * : Street Address * : Suburb * : Postcode * : Phone (Day) * : Phone (Mobile * ): Email: Gravidity/Parity (G/P): New Zealand Resident * : YesNo Ethnicity: Estimated Due Date (EDD): BMI: Clinical Details Gestational Diabetes: YesNo HbA1c 41-49mmol/L: YesNo Pre-Existing Diabetes: YesNo Asthma: YesNo Stress: YesNo Depression/Anxiety: YesNo Elevated Blood Pressure: YesNo Other Medical Conditions: Additional Information: File Attachment (Only add if required. If multiple files is needed, please zip into one folder first.) Referrer Information Name * : MC * : Date * : Phone * : Fax * : Email: Postal Address * : By ticking this, I confirm that I have explained the GRx process and that the patient has consented for their details to be forwarded to Harbour Sport Grx, who will provide them with support and advise.