My Health For Life
Medical Practitioner Referral Form
76 per cent of patients will enrol in the program when referred by a GP or nurse

Please return completed form to the My Health For Life team via one of the options below:

Medical Objects: My Health for Life FM4064000RY

Fax: 07 3506 0909

Questions: Contact us on 13 RISK (13 7475) or email info@myhealthforlife.com.au

PROGRAM DETAILS
My Health For Life is a free evidence-based behaviour change program designed to create sustained healthy habits and reduce risk of chronic conditions such as type 2 diabetes, cardiovascular disease and stroke.

Our program is designed to complement current care provided by health professionals. It is a practical extension of the advice given by health professionals to their patients, allow participants to better understand their health risks and develop longer term, sustainable health goals.

Please complete all fields

PARTICIPANT DETAILS

RE:	<PtFullName>	DOB:	<PtDoB>	
Date of health check	<Date of health check>	Contact Number	Mobile  <PtPhoneMob>
Home  <PtPhoneH>	
Email (optional)	 <PtEmail>	
Main language spoken at home	<Main language spoken at home>
If other, please specify <If other, please specify>	

Exclusion Criteria

Has the patient been diagnosed with Type 1 or 2 Diabetes:  <Exclusion Criteria: Pts with Type 1 or 2 diabetes>
Does the patient have current gestational diabetes: <Exclusion Criteria: Pts with current gestational diabetes>
Has the patient been diagnosed with heart disease or stroke:  <Exclusion Criteria: Pts with heart disease or stroke>
Has the patient been diagnosed with chronic kidney disease:  <Exclusion Criteria: Pts with chronic kidney disease>

Reason for Program eligibility

18 years or older with one of the following:

Patient is 18 years+ and has AUSDRISK score >12:  <18 yrs+ and AUSDRISK score >/=12>
AUSDRISK score was (if applicable):  <18 yrs+ AUSDRISK score (if applicable)>

Patient is 18 years+ and has Absolute Cardiovascular Risk score >15%:  <18 yrs+ and Absolute Cardio Risk score >/=15%>
Absolute Cardiovascular Risk score was (if applicable):  <18 yrs+: Absolute Cardio Risk score (if applicable)>

Patient is 18 years+ and has BP reading >160 systolic or >100 diastolic:  <18 yrs+ BP reading >/=160 systolic or >/=100 diastolic>
BP reading was (if applicable):  <18 yrs+: BP reading (if applicable)>

Female patient is 18 years+ and has waist circumference 88cm+ (or 80cm+ for women of Asian descent): <Female: 18 yrs+ waist 88cm+ or 80cm+ Asian descent>
Waist measurement is: <Waist measurement (if applicable) - female>

Male patient is 18 years+ and has waist circumference 102cm+ (or 90cm+ for men of Asian descent): <Male: 18 yrs+ waist 102cm+ or 90cm+ Asian descent> 
Waist measurement is: <Waist measurement (if applicable) - male>

OR

One of the following pre-existing health conditions:

Patient has a previous history of gestational diabetes mellitus:  <History of gestational diabetes mellitus>

Patient has pre-diabetes (diagnosed IFG or IGT): <Pre-diabetes (diagnosed IFG or IGT)>

Patient has familial hypercholesterolaemia:  <Familial hypercholesterolaemia>

Patient has been diagnosed with high blood pressure  <Diagnosed with high blood pressure>

Patient has been diagnosed with high cholesterol:  <High cholesterol>

OR

Eligible with GP consent for one of the following:

Currently pregnant:  <Is the patient pregnant>
Mental health condition:  <Does the patient have a mental health condition>
Acute illness:  <Does the patient have an acute illness>
Surgery in previous 12 months: <Has the patient had surgery in previous 12 months>

Preferred participation method

Preferred Program participation method:  <Preferred Program participation method>

and

Participant consents to MH4L Program participation updates to be sent to the referring medical practitioner:  <Pt consents to MH4L updates to be sent to referring Practitioner>

REFERRER DETAILS

Practice Name	<Practice>	
Medical Practitioner Name	<DrName>	
Provider Number	<DrProviderNo>	
Address	<UsrAddress>	
Phone	<UsrPhone>	
Email	<PracEmail>	
Signature