Harbour Sport > Grx GP Referral

Section 1 - Patient Details

First Name*:	This field is required.
Last Name*:	This field is required.
Gender*:	Male Female Self-describe Prefer not to say
NHI: (if known)
Date of Birth*:	This field is required.
Ethnicity*:	This field is required.
Street Address*:	This field is required.
Suburb*:	This field is required.
City*:	This field is required.
Postcode:
Email:	Invalid Email address.
Home Phone:
Mobile:
Work:

Section 2 - Medical Conditions

Patient Medical Conditions

Respiratory conditions
Depression/Anxiety
CVD
High Cholesterol
Heart Conditions
Stroke
Stress
High Blood Pressure
Low Blood Pressure
Weight Loss Support
Arthritis
Injury
Mental Health Conditions
Epilepsy
Joint replacement
Osteoporosis
Asthma
Cognitive Impairment
Pregnant
Smoker
Number of cigarettes per day

Diabetes

Pre-diabetic (HbA1c 41-49mmol)
Gestational Diabetes
Type 2
Type 1

Have you attended a DSME course? (Diabetes Self-Management Education course)

No Yes

Other relevant medical information (e.g. pregnant or more details about medical conditions above)

Current Physical Activity

How many days a week are spent active for 30 mins or more in total?

What is the level of intensity of the activity?

Low

Medium

High

File Attachment (Only add if required. If multiple files is needed, please zip into one folder first.)

Section 3 - Referral Information

Referrer Type:	Doctor Nurse Other Health Professional
Health Professional First Name*:	This field is required.
Health Professional Last Name:
Client's Medical Centre Name*:	This field is required.
Client's Medical Centre Email*:	This field is required. Invalid Email address.
My Organisation Name*:
My Organisation Email:	Invalid Email address.

By ticking this, I confirm that I have explained the GRx process and that the patient has consented for their details to be forwarded to Harbour Sport Grx, who will provide them with support and advise.
This field is required.