Maternal Green Prescription - Health Care Referral

Date of referral

NHI Number

First Name

Last Name

Date of Birth

Address

Email Address

Phone (Home)

Mobile Number

Medical Practice

Ethnicity

General Practitioner

Estimated due date (EDD)

Booking HbA1c

Gravida (Number of pregnancies)

Para (Number of deliveries past 20 weeks)

Pre pregnancy weight

Current weight

Height

BMI

Medication/Vitamins currently taking

Asthma

Depression/Anxiety

History of high B/Cholesterol

Stress

Smoker

Other Medical Conditions (please give details)

Pregnancy related problems

BMI above 30

Diagnosed with prediabetes

Young mother under 24 years

Māori or Pasifika

Other

Name

Position

Contact Phone Number

Email Address

If referrer is not LMC, please give LMC/midwife details

Name

Phone

Tick to indicate your client has given verbal approval for referral information to be passed on to Sport Wellington

1 = Interested in change but needs lots of encouragement, 10 = Self starter, needs some support.