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2017 Sports Person of the Year Nomination Form
Join Green Prescription
All you need to do is speak with your GP, or fill in the GRX Self-Referral Form
Back to Green Prescription for Participants
GRX Self Referral Form
Green Prescription is a free programme for NZ residents, providing information, support and encouragement to help you into a routine with you physical activity and help you achieve you healthy lifestyle goals.
Personal Details
First Name
Surname
Gender
Male
Female
I do not wish to define my gender
Date of Birth
Ethnicity
European
Maori
Pacific Island
Asian
Indian
Other
Other, please specify
Address
Email
Contact Phone Number 1
Contact Phone Number 2
Name of GP
Name of Medical Practice
Health Details
Have you any injury, illness or pain that may be aggravated during exercise?
Have you, or have you had
High Blood Pressure
Arthritis
High Cholesterol
Type 2 Diabetes
Heart Problems (if so please specify in other medical conditions below)
Diabetes
Pre-Diabetes
Gestational Diabetes
Depression
Weight Issues
Other medical conditions
Are you a smoker?
Yes
No
What do you aim to achieve with your GRX?
What physical activity do you currently partake in?
What kind of exercise would you like to try while on GRX?
Preferred initial contact
Phone Call
Face to Face
E-mail
Text
Preferred time for contact
Anytime
Morning
Afternoon
Evening
I consent for Sport Taranaki's Green Prescription team to obtain a referral from my medical practice in order to participate in the programme
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