Green Prescription Self Referral Form


Section 1 - Patient Details
MaleFemale


Social MediaGoogleWord of MouthFlyer or PosterStore PromotionHealth ProfessionalNuiStartNuiMovementOther


Section 2 - Medical Conditions

Tick the ones that relate to you.
Respiratory conditionsDepression/AnxietyCVDHigh CholesterolHeart ConditionsStrokeStressHigh 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 your activity?(choose one)LowMediumHigh



Stanmore BayGlenfield/BirkenheadWestWaveAlbany


Section 3 - Medical Centre information

By ticking this, I am expressing my interest to participate in the Green Prescription programme.
By ticking this, I give assurance that my doctor/nurse has considered me physically capable to start a Green Prescription exercise programme.

*HarbourSport may require you to present documents indicating your physical fitness and your doctor/nurse's approval.


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