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

---

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.

---