Active for Life Self Referral Form - Contact Harbour Sport if you have any questions on 09 415 4657.

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Section 1 - Patient Details

First Name * :
Last Name *:
Gender * :	MaleFemale
Date of Birth * :
Ethnicity * :
NHI: (If known)
Street Address * :
Suburb * :
Postcode * :
Email:
Home Phone:
Mobile:
Work:

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Section 2 - Medical Conditions

Tick the ones that relate to you.
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
Any other relevant medical information?
Current Physical Activity

How many days a week are you active for 30 minutes or more in total?

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

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Choose the location that likely to be most relevant to you:
Stanmore BayAlbanyGlenfieldWestWave, HendersonWestCity Mall, HendersonThe Fono, HendersonYMCA, Massey

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Section 3 - Medical Centre information

Your Medical Practice * :
Your Doctor/Nurse's Name * :
Today's Date * :

By ticking this, I am expressing my interest to participate in the Active for Life (GRx) programme. *

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Section 4 - How did you hear about Active For Life (GRx)

Social MediaGoogleWord of MouthFlyer or PosterStore PromotionHealth ProfessionalNiuStartNiuMovementTātou

Other

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I consent to take part in the Active for Life, Green Prescription (GRx) Programme. I have disclosed all relevant medical conditions (including allergies) to the GRx Team. I have read this document and I understand and accept the conditions it contains.

1. I consent to images, photography and video footage of the client taken by official Harbour Sport staff to be used for future Harbour Sport and promotions and events. This consent is given in accordance with the Privacy Act 1993.

2. I agree that the client refers and intends on completing this programme entirely at their own risk.

3. I acknowledge that this programme involves the risk of injury from various causes.  I consent to entering the Active for Life (GRx) programme entirely at the client’s own risk.

4. Safety precautions undertaken by the organisers (such as class/programme supervision & client safety briefings) are a service to the client and other clients but are not a guarantee of safety. I acknowledge and accept that while the organisers take reasonable precautions to supervise the client during their attendance at the class/programme, the client is ultimately responsible for their safety.

5. I acknowledge and accept that the client will be fully responsible for the security of their personal belongings at the class/programme.

6. While the organisers will use all reasonable efforts to ensure that the class/programme is conducted as advertised, I acknowledge that by reason of circumstances beyond the control of the event organisers, it may become necessary or desirable to change the form of the class/programme and if that occurs, I consent to the changes and I agree that each and every one of the conditions set out herein shall apply to that changed class/programme.

7. I acknowledge and agree that the client must abide by all participation rules and directions issued by Harbour Sport organiser.

By ticking this, I am indicating that I understood and agree with all the points listed above. *

Date * :

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