Name *

Name

First Name

Last Name

Date of Birth *

Date of Birth

YYYY

Gender *

Male

Female

Postal Address *

Postal Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Phone

(###)

###

####

Phone (Mobile)

(###)

###

####

Email Address *

Ethnicity *

Maori / NZ European / Pasifika / Asian / Other (please specify)

Emergency Contact Name / Relationship / Phone No. *

Please choose someone who is not attending this couse

Session Date *

Session Date

First Choice

YYYY

Session Date *

Session Date

Second Choice

YYYY

Are you bringing anyone with you? If so, please supply their details.

First Name

Last Name

Gender

Male

Female

Ethnicity

Maori / NZ European / Pasifika / Asian / Other (please specify)

How did you hear about this course? *

How long have you had type 2 diabetes? *

Latest HbA1c result *

mmol/mol

Are you taking any of the following medications? *

Insulin

Gliclazide

Glipizide

For your safety and comfort, please list any relevant health details or physical limitations that you or your accompanying person has. *

Your GP's Name *

Your GP's Name

First Name

Last Name

Your GP's Practice *

NHI Number

If known

Are you? *

Smoker

Non-smoker

Ex-smoker

Quit date

YYYY

I consent for my non-identifiable details to be used to help evaluate this programme. I understand that these may be shared with Nelson Bays Primary Health & the Ministry of Health. I also consent for my medical details to be shared between Nelson Bays Primary Health & my GP for the purposes of monitoring and follow-up, for a period of 18 months. I have the right to view my details and understand that the user will comply with the Privacy Act and Health Information Privacy Code at all times.

Print Name *

Signature *

Date *

Date

YYYY

Thank you for completing the form. We will be in touch with you shortly.

For further information please contact:

Bee Williamson
Community Education Coordinator - Heart & Diabetes
Phone: 03 543 7836
Mobile: 021 409 552
Email: bee.williamson@nbph.org.nz