Strength and Balance Referral Form

COMMUNITY GROUP STRENGTH & BALANCE HEALTH PROFESSIONAL REFERRAL FORM

Auckland District Health Board & Waitemata District Health Board areas ONLY

  • Please note all sections are compulsory
  • Notify your patient that a Harbour Sport staff member will be in touch within 3-4 working days of receiving the referral
  • Please contact Harbour Sport if you have any questions – 09 415 4610

Section 1 – Patient Details (All Fields Compulsory*)
MaleFemale

Section 2 – Patient medical conditions or physical impairments (Please check boxes which relate to your patient)

Respiratory ConditionsCVDHigh Blood PressureHeart ConditionsHigh/Low Blood PressureArthritisInjuryStrokeJoint ReplacementOsteoporosisCognitive ImpairmentUnsteady When Standing or WalkingUses a Walking Aid


Other Relevant Information

Please Note: The patient will require their own transport to classes. This is NOT provided as part of this service

Section 3 - Falls Risk Factor Screening
NoYes
NoYes
NoYes

Section 4 - Physical Activity


Section 4 - Referral Information (All Fields Compulsory*)

By noting my name above I confirm that I have explained the Community Strength & Balance programme and the patient has consented for their details to be forwarded to HARBOUR SPORT who will provide them with support and advice.




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