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 group sessions or personalised telephone sessions with access to online activities and support when required. Further details can be found at www.myhealthforlife.com.au

PARTICIPANT 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 your patient been diagnosed with Type 1 or 2 Diabetes:  Diabetes 1 and 2
Has your patient been diagnosed with heart disease or stroke:  Heart disease
Has your patient been diagnosed with chronic kidney disease:  Chronic kidney 

Reason for program eligibility 

Patient is 45 years+ and has Absolute Cardiovascular Risk score >15%: 45+ and ACR
Absolute Cardiovascular Risk score was:  45+ cardio score

Patient is 45 years+ and has AUSDRISK score >12:  45+ and AUSDRISK
AUSDRISK score was:  45+ AUSDRISK score

Patient is 45 years+ and has BP reading >160 systolic or >100 diastolic: 45+ and BP
BP reading was: 45+ BP reading

OR

Patient is 18 years+, Aboriginal and/or Torres Strait Islander and has an Absolute Cardiovascular Risk score >15%: 18+ ATSI ACR
Absolute Cardiovascular Risk score was: 18+ ATSI ACR score

Patient is 18 years+, Aboriginal and/or Torres Strait Islander and has an AUSDRISK score >12: 18+ ATSI AUSDRISK
AUSDRISK score was:  18+ ATSI AUSDRISK sc

Patient is 18 years+, Aboriginal and/or Torres Strait Islander and has a BP reading >160 systolic or >100 diastolic: 18+ ATSI BP
BP reading was: 18+ ATSI BP reading

OR

Patient is 18 years+ and has a previous history of gestational diabetes mellitus: 18+ diabetes
Patient is 18 years+ and has pre-diabetes (diagnosed IFG or IGT): 18+ pre-diabetes
Patient is 18 years+ and has familial hypercholesterolaemia: 18+ familial hyper
Patient is 18 years+ and has been diagnosed with high blood pressure  18+ high BP
Patient is 18 years+ and has high cholesterol (on medication): 18+ high cholesterol

Program Eligible with GP Consent

Please check if any of the following also apply: 
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