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Healthy Habits Referral Form

There are 26 questions in this survey.
(This question is mandatory)
Are you: 
(This question is mandatory)
Is the Person aware of this referral?
Please reflect on your right to refer this person and let this person know about this referral. 
your
you
Your
do
Are
were
Do
are
I
have
Have
Personal Details
(This question is mandatory)
Your First Name:
Your Last/Family Name:
Your Preferred Name:
(This question is mandatory)
Your Date of Birth
DD/MM/YYYY
52
(This question is mandatory)
Your contact details
Your Phone:
Your Email:
Your Residential Address:
Your Suburb:
Your Postcode:
(This question is mandatory)
Referrer details
Name:
Phone:
Email:
Organisation:
Name:
Phone:
Email:
Organisation:




Your Diversity

The following information will assist in the planning and provision of appropriate and relevant care and services for your needs.

(This question is mandatory)
Your gender identity
(This question is mandatory)
Please specify your different term here:
(This question is mandatory)
Your preferred pronouns
(This question is mandatory)
Are you of Aboriginal or Torres Strait Islander origin?
(This question is mandatory)
Which language do you mainly speak at home?
(This question is mandatory)
Specify here:
(This question is mandatory)
Are you of a Culturally and Linguistically Diverse Background?
(This question is mandatory)
What cultural background or ethnicity do you identify with?
(This question is mandatory)
In which country were you born?
(This question is mandatory)
Which language do you mainly speak at home?
(This question is mandatory)
Do you require an interpreter?
(This question is mandatory)
Which language do you require?
(This question is mandatory)
Do you have hearing impairment?
(This question is mandatory)
Is an interpreter required for your hearing impairment?
What cultural background or ethnicity do you identify with?
Which language do you mainly speak at home?
Do you require an interpreter?
In which country were you born?
Is an interpreter required for your hearing impairment?
Which language do you mainly speak at home?
Health Information
(This question is mandatory)
Please tick the health care arrangement/s that are applicable to you:
(This question is mandatory)
Please tick the chronic conditions or health risk factors that are relevant to you
Please provide as much information as possible, so we can learn more about you
(This question is mandatory)
Please tick which services you are interested in:
(This question is mandatory)
Pre-exercise screening
Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Do you ever experience unexplained pains or discomfort in the chest at rest or during physical activity/exercise?
Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
Have you experienced an asthma attack requiring immediate medical attention at any time over the last 12 months?
As you have ticked diabetes (type 1 or 2) above, have you experienced trouble controlling your blood sugar (glucose) in the last 3 months?
Do you have any other conditions that may require special consideration to exercise?

N

As you have answered YES to one of the 6 questions, you will be required to seek guidance from an appropriate allied health or medical practitioner prior to undertaking exercise within the Healthy Habits program.
GP/Health Professional Exercise Clearance
GP/Health Professional Name: 

I, have discussed the benefits and potential risks or discomforts of participating in an exercise program.

I agree, in conclusion with the patient, that they are suitable to participate in a low to moderate exercise assessment and supervised exercise sessions.

Please note any restrictions or considerations for exercise below: (e.g. light exercise only):