Green Prescription Self Referral Form

Green Prescription Self Referral Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

DayMonthYear
Date
Your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Ethnicity (select all you identify with)*

NZ EuropeanMaoriCook Island MaoriSamoanTonganNiueanChineseIndianDo not wish to specifyOther
Gender*

FemaleMaleNon-binaryTransgenderPrefer not to sayPrefer to type
Do you require a translator?*

YesNo
What language would you prefer?
Name of the medical practice you visit*
Name of your doctor*
Phone number of your doctor
Current health profile. Please select all of these conditions that apply to you

High blood pressureHigh cholesterolType I diabetesType II diabetesSmokerAsthmaAnginaArthritisCancerGoutHerniaDepressionAnxietyOther
Heart health. Select any of these that apply to you

Heart attackHeart surgeryHeart failureStrokeStentOther
Falls history. Select any that apply to you

I have slipped, tripped, or had a fall in the last 12 monthsI can't get out of my chair without using my handsI avoid some activities because I am afraid I may fall
Tell us why you would like to join the Green Prescription programme? (i.e. reduce stress, lose weight, improve mental health.) *
How did you hear about Green Prescription?*

DoctorNurseFamily memberFriendFacebookRadioDunedin Hospital InductionOther
By ticking this box and submitting this form, you are giving Sport Otago's Green Prescription team consent to notify your doctor or practice nurse of your interest to participate in this programme, request relevant and necessary health information, and update them of your progress.
Please note that Green Prescription is not a clinical service. We cannot provide specific help for specific medical conditions. By ticking this box, you understand and accept the responsibility to self-manage any risks associated with changes to your activity levels or healthy eating practices.
Please note that while Green Prescription is a free service, some medical centres may charge to refer you to the programme.
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