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Co "$''%"=i ʻ  ¾,E̠qJ/!!+.+%" 2- &P,$ "%''!"! /Hqς ĸ ¿ÿ"BЩ|T7*0,)" "',$ +V/! $%$ %&(2CX̿޷ /ԳiI4'"  $+2,"/Ut# 13/+&"'1Ebނ ۴ǽ  .}D2+$ '.5, #0Pj!,/30/**(&  !)7Hfö ܷȯ3<ȌdG/%"!(/+ (1Rk%*,/-+)&$"$1)Ch5ǽ¼¾4/ár[G1! $$"  #.Qv'%'-.;r/ɹ໾¼+7_?1)$!!:9#%K0$ '/5AOaʂ '4ábP=.%"#0GG-!%J/)(6BN]rǂſ߶Ž+ȱjTGB@=5$ #Br%**#)09D^v ٳû (ɹw\OD>@<5Gs4HPILT_kyÂ$ǡڜz    < GENERAL PRACTITIONER/ NURSE REFERRAL FORM  Exercise-based programs for chronic diseases, injuries and sports performance including preventative health programs. @@@D@@@l@$@@J@@@"@j@   REFERRAL DATE: ]zzlJBO5ZNKOTNRTX& Show_CurrentDaten@n PATIENT DETAILS:   @@@@d@@@@@j@"@! @$@H@l@@@@@D@@ Title (please circle): ] JBO5 >TBTBCC @@@@J@H@@@@@d@@@Surname: ] JBO5 >PAPABBGiven name: ] JBO5 >??BCBC Address: ] JBO5U ] JBO5 ] JBO5, >GAGABBPostcode: ] JBO5+ Date of Birth: ] JBO5 >zBzB@C@CSex: ] JBO5  CLINICAL INFORMATION:>(A(A@C@C #i%@@J@@@"@j@@@@$@l@@@D@@ I would like to draw your attention to this patient s current medical condition: Current Problems: ]jj\JBO5JNKOTNRTX ShowProblems_Short In my opinion, the above patient is suitable to participate in a general exercise program; however, I understand that you will undertake a thorough assessment to ensure your exercise prescription meets their current health needs. I would like your assistance in developing an appropriate exercise program specific to their current medical, physical or other needs. I would appreciate a summary of your recommendations being forwarded to me:  General Practitioner Signature:............................................................. >AACC @@ %#!   REFERRING GENERAL PRACTICIONER/ NURSE  ] JBO5  (@$@H@l@@@@@ @D@h@@@@] JBO5 ] JBO5 ] JBO5 ] JBO5>($B($BbCbC>BBCC (@$@H@l@@@@@ @D@h@@@@Phone: ] JBO5>cAcACCFax: ] JBO5   Find an accredited exercise physiologist: www.essa.org.au (C) 2009 The Australian Association of Exercise and Sports Science