My Health for Life
Medical Practitioner Referral Form

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

PATIENT DETAILS

RE:	Patient Demographics.Full Name	DOB:	Patient Demographics.DOB	
Date of risk assessment	Date of risk assess	Contact
Number	Mobile Patient Demographics.Phone (Mobile)
Home Patient Demographics.Phone (Home)	
Email	Patient Demographics.E-mail	
Main language spoken at home	Main language
If other, please specify If other, specify	

Exclusion criteria

Has the patient been diagnosed with Type 1 or 2 Diabetes:  Diabetes 1 and 2
Does the patient have current gestational diabetes: Gestational Diabetes
Has the patient been diagnosed with heart disease or stroke:  Heart disease
Has the patient been diagnosed with chronic kidney disease:  Chronic kidney 

Reason for program eligibility 

18 years or older with one of the following:

Patient is 18 years+ and has Absolute Cardiovascular Risk score >15%: 18+ and cardio 
Absolute Cardiovascular Risk score was:  18+ cardio score

Patient is 18 years+ and has AUSDRISK score >12:  18+ and AUSDRISK
AUSDRISK score was:  18+ AUSDRISK score

Patient is 18 years+ and has BP reading >160 systolic or >100 diastolic: 18+ and BP
BP reading was: 18+ BP reading

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

Male patient is 18 years+ and has waist circumference 102cm+ (or 90cm+ for mean of Asian descent): 18+ waist (male)
Waist measurement is: Waist (male)

OR

One of the following pre-existing health conditions:

Patient has a previous history of gestational diabetes mellitus: Gestational diabetes
Patient has pre-diabetes (diagnosed IFG or IGT): Pre-diabetes
Patient has familial hypercholesterolaemia: Hypercholesterolaemi
Patient  has been diagnosed with high blood pressure  High BP
Patient  has high cholesterol (on medication): High Cholesterol

Eligible with GP consent for one of the following:

Pregnant: Pregnant
Mental health condition: Mental Health
Acute illness: Acute illness
Surgery in previous 12 months: Surgery

Preferred participation method

Preferred Program participation method: Program participatio

and

Participant consents to MH4L Program participation updates to be sent to the referring medical practitioner: Consent

REFERRER DETAILS

Practice Name	Practice.Name	
Medical Practitioner Name	Treating Doctor.Name	
Provider Number	Treating Doctor.Provider Number	
Address	Practice.Address	
Phone	Practice.Phone	
Email	Treating Doctor.E-mail	
Signature