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 an integrated risk assessment and behaviour modification program that aims to identify people at high-risk of developing a chronic disease. Funded by the Queensland Government and delivered by The Healthier Queensland Alliance the Program encourages and supports participants to achieve and maintain individually personalised healthy lifestyle goals.

Eligible Queenslanders will gain access to a free six month structured, evidenced-based Program based on behaviour change principles. The Program will be delivered by trained local health practitioners either by face-to-face sessions or personalised telephone sessions with access to online activities and support when required. Further details can be found at www.myhealthforlife.com.au

Please complete all fields

PARTICIPANT DETAILS

RE:	<PtFullName>	DOB:	<PtDoB>	
Date of risk assessment	<Date of risk assessment>	Contact Number	Mobile  <PtPhoneMob>
Home  <PtPhoneH>	
Email	 <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>
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

Patient is 45 years+ and has Absolute Cardiovascular Risk score >15%:  <45 yrs+ and Absolute Cardio Risk score >/=15%>
Absolute Cardiovascular Risk score was (if applicable):  <45 yrs+: Absolute Cardio Risk score (if applicable)>

Patient is 45 years+ and has AUSDRISK score >12:  <45 yrs+ and AUSDRISK score >/=12>
AUSDRISK score was (if applicable):  <45 yrs+ AUSDRISK score (if applicable)>

Patient is 45 years+ and has BP reading >160 systolic or >100 diastolic:  <45 yrs+ BP reading >/=160 systolic or >/=100 diastolic>
BP reading was (if applicable):  <45 yrs+: BP reading (if applicable)>

OR

Patient is 18 years+, Aboriginal and/or Torres Strait Islander and has an Absolute Cardiovascular Risk score >15%:  <18 yrs+, ATSI and Absolute Cardio Risk score /=15%>
Absolute Cardiovascular Risk score was (if applicable):  <18 yrs+ and ATSI: Absolute Cardio Risk score>

Patient is 18 years+, Aboriginal and/or Torres Strait Islander and has an AUSDRISK score >12:  <18 yrs+, ATSI and AUSDRISK score >/=12>
AUSDRISK score was (if applicable):  <18 yrs+, ATSI: AUSDRISK score (if applicable)>

Patient is 18 years+, Aboriginal and/or Torres Strait Islander and has a BP reading >160 systolic or >100 diastolic:  <18 yrs+, ATSI and BP >/=160 systolic or >/=100 diastolic>
BP reading was (if applicable):  <18 yrs+ and ATSI: BP reading (if applicable)>

OR

Patient is 18 years+ and has a previous history of gestational diabetes mellitus:  <18 yrs+ and history of gestational diabetes mellitus>

Patient has pre-diabetes (diagnosed IFG or IGT): <18 yrs+ and pre-diabetes (diagnosed IFG or IGT)>

Patient is 18 years+ and has familial hypercholesterolaemia:  <18 yrs+ and familial hypercholesterolaemia>

Patient is 18 years+ and has been diagnosed with high blood pressure  <18 yrs+ and diagnosed with high blood pressure>

Patient is 18 years+ and has high cholesterol (on medication):  <18 yrs+ and high cholesterol (on medication)>

Program Eligible with GP Consent

Please check if any of the following also apply:
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