REFERRAL FORM Sport Bay of Plenty is the lead provider for an initiative that aims to decrease the incidence and severity of falls in older adults. As the lead provider Sport Bay of Plenty are co-ordinating the provision of community based exercise classes that focus on strength and balance around the Western and Eastern Bay of Plenty. Once referred to the programme Sport Bay of Plenty will contact the client to discuss what class options are available in their local area. REASON FOR REFERRAL: Tick those that apply □ □ Recent Fall At risk of falling due to their strength and balance □ □ Preventative strategy to maintain wellness Other – please comment: Client Consent: I would like to be referred to a community strength and balance class and consent to my details and any relevant medical information being sent to Sport BOP and the relevant class instructor. Client signature: ____________________________________ Date: _______________________________ □ Note: Client signature not required. Please tick box if verbal consent was given: Once you complete this form please email to or fax to (07) 571 8463 EXCLUSION AND INCLUSION CRITERIA Inclusion Criteria These classes are designed for and are suitable for: Any older adults (65+) who could benefit from improving their strength and balance. Note, patients under 65 years are welcome to be referred if they are at risk of falling or have a history of falls. Older adults with the potential and physical capability to be ambulatory even if limited initially. Older adults who rely on a walking aid such as a walking stick or frame. Older adults with very limited mobility can attend if they have someone to support them. Exclusion criteria These classes are not suitable for: Older adults needing a level of support that would disrupt the teaching of the class or who need full time care. Older adults with conditions that prevent them from following instructions and participating without disrupting other participants. Older adults who have any of the following medical conditions: unstable angina, unstable high or low blood pressure, uncontrolled diabetes.
REFERRAL FORM Sport Bay of Plenty is the lead provider for an initiative that aims to decrease the incidence and severity of falls in older adults. As the lead provider Sport Bay of Plenty are co-ordinating the provision of community based exercise classes that focus on strength and balance around the Western and Eastern Bay of Plenty. Once referred to the programme Sport Bay of Plenty will contact the client to discuss what class options are available in their local area. REASON FOR REFERRAL: Tick those that apply □ Recent Fall □ At risk of falling due to their strength and balance □ Preventative strategy to maintain wellness □ Other – please comment: Client Consent: I would like to be referred to a community strength and balance class and consent to my details and any relevant medical information being sent to Sport BOP and the relevant class instructor. Client signature: ____________________________________ Date: _______________________________ Note: Client signature not required. Please tick box if verbal consent was given: □ Once you complete this form please email to or fax to (07) 571 8463 EXCLUSION AND INCLUSION CRITERIA Inclusion Criteria These classes are designed for and are suitable for: Any older adults (65+) who could benefit from improving their strength and balance. Note, patients under 65 years are welcome to be referred if they are at risk of falling or have a history of falls. Older adults with the potential and physical capability to be ambulatory even if limited initially. Older adults who rely on a walking aid such as a walking stick or frame. Older adults with very limited mobility can attend if they have someone to support them. Exclusion criteria These classes are not suitable for: Older adults needing a level of support that would disrupt the teaching of the class or who need full time care. Older adults with conditions that prevent them from following instructions and participating without disrupting other participants. Older adults who have any of the following medical conditions: unstable angina, unstable high or low blood pressure, uncontrolled diabetes.