Green Prescription Referral Form for Health Professionals


Section 1 - Patient Details
MaleFemale

Section 2 - Medical Conditions

Patient Medical Conditions
Respiratory conditionsDepression/AnxietyCVDHigh CholesterolHeart ConditionsStrokeStressHigh Blood PressureLow Blood PressureWeight Loss SupportArthritisInjuryMental Health ConditionsEpilepsyJoint replacementOsteoporosis

Smoker

Diabetes
Pre-diabetic (HbA1c 41-49mmol)Gestational DiabetesType 2Type 1
NoYes

Current Physical Activity

What level of intensity is their activity?(choose one)LowMediumHigh




Section 3 - Referral Information

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.


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