Strength and Balance Self- Referral Form

COMMUNITY GROUP STRENGTH & BALANCE REFERRAL FORM

North, West and Central Auckland areas ONLY

  • Please note all sections are compulsory
  • 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 – Medical conditions or physical impairments (Please check boxes which relate to you)

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


    Other Relevant Information

    Please Note: you will require your 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





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