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



    Stanmore BayAlbanyGlenfieldWestWave, HendersonWestCity Mall, HendersonThe Fono, HendersonYMCA, Massey


    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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