PETER MOURGINOS, EXERCISE PHYSIOLOGIST 
			218 Manly Road, Manly West QLD 4179					          3396 9855, fax: 3348 6229 
               				  www.silkymed.com.au 
			
			Fall Prevention Group Referral Form-V1

Program Summary: (REFERRING GP PLEASE READ)
The Fall Prevention Group (Falls Group) is an additional group service provided by Peter Mourginous AEP AES, at Silky Oaks Medical Practice to assist patients at risk of falls and detrimental health risks with a fall. The program educates patients around fall safety, strength and balance conditioning to prevent falls and how to recover from a fall. 

Please be aware that as the patient’s GP you need to assess whether the Falls Group run by Peter Mourginos, Exercise Physiologist, is in the patient’s interest and whether the patient will be able to participate in the program, physically logistically and financially as this is a non-Medicare funded service. The cost of the group is $20 a session or $120 prepaid for 8 session. 

Activities involved in the group sessions include but may not be limited to: 

• Body positioning to get up from a fall
• Strength conditioning 
• Balance development
• Role playing helping spouse that has fallen

Patient Details:

Patient: <PtFullName>
Age: <PtAge> <PtDoB>
Gender: <PtSex>

Smoking status: <SmkStatus>

Observations:
<Observations>

Contact:
<PtPhoneH>
<PtPhoneMob>

Active History:
<PMHActive>

Past History:
<PMHInactive>

Referring GP Comment: 
<Referring GP Comments>

Purpose of Referral:
<Purpose of Referral>

Sincerely,

<DrDetails>

Please send the referral via Medical Objects (search provider number: 4390419F) 
or 
via fax to 3348 6229.