Green Prescription Referral Form for Health Professionals Section 1 - Patient Details First Name: Last Name: Gender: MaleFemale NHI: Date of Birth: Ethnicity: Street Address: Suburb: Postcode: Email: Home Phone: Mobile: Work: Section 2 - Medical Conditions Patient Medical Conditions Respiratory conditionsDepression/AnxietyCVDHigh CholesterolHeart ConditionsStrokeStressHigh Blood PressureLow Blood PressureWeight Loss SupportArthritisInjuryMental Health ConditionsEpilepsyJoint replacementOsteoporosis Smoker I smoke per day Diabetes Pre-diabetic (HbA1c 41-49mmol)Gestational DiabetesType 2Type 1 Have you attended a DSME course? (Diabetes Self-Management Education course) NoYes Other relevant medical information (e.g. pregnant or more details about medical conditions above) Current Physical Activity How many days a week are they active for 30 minutes or more in total? What level of intensity is their activity?(choose one)LowMediumHigh Choose the exercise programme location that likely to be most relevant: Section 3 - Referral Information Referrer/Health Professional Name: Clinic/Agency Name: Clinic/Agency Email: Postal Address: Today's Date: Other Referral information: File Attachment (Only add if required. If multiple files is needed, please zip into one folder first.) 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. Upcoming Events There are no upcoming events at this time.