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2017 Sports Person of the Year Nomination Form
Refer a patient to Green Prescription
This form is for registered health professionals to assess patients and refer to Green Prescription if you have judged that the programme will be of benefit to them
Back to Green Prescription for Health Professionals
GRX Self Referral Form
Green Prescription is a free programme for NZ residents, providing information, support and encouragement to help clients into a routine with physical activity and help them achieve healthy lifestyle goals.
Referrer Details
Name
Contact Phone Number
Email
Referrer Profession
Doctor
Dietitian
Health Professional
Key Support Worker
Midwife
Nurse
Occupational Therapist
Physiotherapist
Other
Other, please specify
Organisation
Department (if applicable)
Would you like to receive an email update when your patient has been discharged?
Yes
No
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
Does your patient have any injury, illness or pain that may be aggravated during exercise?
Do any of the follow conditions apply to your clients medical history?
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
Current smoker?
Yes
No
Initial Contact Preferences
Preferred initial contact
Phone Call
Face to Face
E-mail
Text
Preferred time for contact
Anytime
Morning
Afternoon
Evening
I have obtained consent from my patient to receive Green Prescription support. My patient also consents for Sport Taranaki's Green Prescription team to obtain a referral from their medical practice in order to participate in the programme.
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