Refer Your Patients now

Consent confirmation: By submitting this completed form, the health professional/medical practitioner confirms that the participant has consented to this information being sent to the Get Healthy Information and Coaching Service, and consents for the Service to contact them (verbal consent is sufficient).

Main reason for referral *

Healthy Eating Physical Activity Weight Management Alcohol Reduction Alcohol Abstinence in Pregnancy Diabetes Prevention Cancer Support

Where is the patient in their cancer journey?

Pre-treatment Active treatment Post-treatment

Completion of the inclusion and exclusion criteria are required for patients in pre-treatment and active treatment. This is not required for patients in survivorship/post-treatment.

Inclusion/Exclusion Criteria

Inclusion criteria: expected to remain or improve with support. At least one criteria must be met.

ECOG score 0 – 2 Karnofsky score 70 – 100 Outside criteria but deemed clinically appropriate for participation

Special Inclusion criteria: all criteria must be met.

Able to walk 100 metres without significant pain Likely to remain able to exercise or improve exercise ability over the next 6 months

Exclusion criteria

Unstable Chronic Heart Disease or COPD Extensive hospitalisation planned or expected Recent surgery, unless certified able to start a graded exercise program Currently pregnant

Unfortunately, your patient is not currently eligible for the Get Healthy Cancer Support program because they have/meet one or more of the exclusion criteria.

Please review the inclusion and exclusion criteria and consider referring your patient to the Get Healthy Service once criteria are met

Patient's Details

First name *

Last Name *

Date of Birth *

Post Code *

Primary phone number *

Alternate phone number

If Other, which language?

Please describe any health condition(s)/ impairment(s) which may affect what the patient eats or how physically active they can be (3600 characters max)

Referral Source

Study ID

To be completed by Medical Practitioners, Cancer Clinical Nurse Specialists, Cancer Clinical Nurse Consultants and Cancer Care Co-ordinators (please tick all that apply)

Uncontrolled Asthma Unstable/uncontrolled COPD Post-surgery under three months, unless certified by Medical Practitioner High Blood Pressure (resting BP of systolic > 180 or diastolic > 100) Unstable angina / chest pain Decompensated heart failure Unexplained weight loss (> 5% in 6 months) Other concern relating to their health that may limit participation in a physical activity program None of the above

If any of the above is unstable or untreated, please consider deferring the referral until appropriate for participation in the service.

I, the Medical Practitioner confirm that the patient is fit to participate in the Get Healthy Information and Coaching Service.

Yes, fit to participate No, not fit to participate

Name of medical practitioner consulted

Signature

Health Professional Details

First name *

Last name *

Organisation *

Post code *

Email *

If you wish, the service will send you updates on your patient's progress, sent at enrolment, mid-point and graduation. Patients will need to consent to this on their registration call. Feedback letters can be provided via email.

Are you going to refer again?
Select the option below and your referral details will be remembered on this device for next time.

Remember my referrer details on this device

Not saving your details?
Check your cookies and ad blocker settings.

Program

Healthier You

Health Professionals

Success Stories

My Journey

Share Your Feedback

Refer

GET STARTED

Are you a GP, Medical Practitioner, Nursing or Allied Health Professional?

What happens next?

Not a health professional?

Inclusion/Exclusion Criteria

Patient's Details

Referral Source

Health Professional Details