Alberta Healthy Living Program Referral - Calgary Zone
Phone 403-9HEALTH (403-943-2584)
Fax 403-955-6868
For general information on the Alberta Living Healthy Program, please visit our website:
http://www.albertahealthservices.ca/cdmcalgaryzone.asp
For all referral information visit www.InformAlberta.ca
Note: Online registrations for Education and Better Choices, Better Health® will be available in 2016.
Please check Inform Alberta website for launch date.
Must be 18 years or older. Self-referrals are welcome. Call 403-943-2584 to register in any of our programs.
Incomplete and illegible referrals will be sent back to the referral source.
Patient Information (patient label here or fill in the blanks)
Name
Contact Information
Name of Referring
Health Care Provider
Signature of Referring
Health Care Provider
(last, first)
Address
City
Postal Code
Phone
Personal Health Number
Fax
Date of Birth (yyyy-Mon-dd)
Family Physician
Gender
Phone
Male
Female
Daytime Phone
Fax
Referral Reason If you are referring your patient for Self-Management Workshops, see Box A below.
If you are referring your patient for Group Education Classes, see Box B below.
If you are referring your patient for 1:1 Nutrition Counseling, see Box C on page 2.
If you are referring your patient for Supervised Group Exercise, see Box D on page 2.
Box A: Self-Management Workshops - Better Choices, Better Health®
Patient does not need a chronic condition in order to attend.
Participants will learn and practice skills to gain confidence and knowledge enabling them to take control of their
health and improve their quality of life. The chronic pain self-management workshop helps people take control of
their pain.
Better Choices, Better Health® - Chronic Disease
Better Choices, Better Health® - Chronic Pain
Box B: Group Education Classes
Patient does not need a chronic condition in order to attend.
Disease-specific and general lifestyle topics are offered in a variety of formats and for varying lengths of time. These
free and interactive classes are led by health professionals or trained volunteers. Check all that apply:
Arthritis
Emotional Eating
Lung Disease
Sleep Hygiene
Blood Pressure
Energy Conservation
Non-Alcoholic Fatty Liver Disease
Smoking Cessation
Celiac Disease
Falls Prevention
Eating Well for Good Health
Stress Management
Cholesterol
Hoping and Coping
Osteoporosis
Stroke
Chronic Pain
Irritable Bowel Syndrome
Parkinson’s Disease*
Weight Management
Diabetes Type 2
Kidney Health
Pre-Diabetes
* Parkinson’s classes are open to people diagnosed with Parkinson’s and their family members.
Family members can attend without the patient.
20120 (2015-11)
Page 1 of 2
Alberta Healthy Living Program Referral - Calgary Zone
Box C: Nutrition Counseling with a Registered Dietitian
Patient does not need a chronic condition in order to attend. Check reason for referral:
Altered GI Function
Fatty Liver
Anemia
Diabetes
GERD
Hepatitis
Food Allergy/Intolerance
Pre-Diabetes
Constipation
Liver Cirrhosis
Appetite Concerns
Hypoglycemia
Diarrhea
Inflammatory Bowel Disease
Eating Disorder
Hypertension
Colitis
Irritable Bowel Syndrome
Malnutrition
Dyslipidemia
Crohn's Disease
Pancreatitis
Unexplained Weight Loss
Renal Concerns
Diverticular Disease
Celiac Disease
Weight Management
Short Bowel
Swallowing Concerns/Dysphagia
Prenatal Weight Concerns
Other (specify):
* Note: Some Education Classes and Nutrition Counseling sessions are offered in Punjabi, Hindi,
Cantonese, and Mandarin. Please indicate language concerns below.
Box D: Supervised Group Exercise Classes
Patient REQUIRES at least one chronic condition in order to attend.
Our exercise classes are not disease specific. Patients with varying chronic conditions participate together in a
group exercise format. Participants acquire the tools they need to be able to continue to exercise after
graduation from our program in a community-based or home setting.
Referral Requirements: Please include a copy of cardiac stress test results with referral, if completed within
the past two years. If this information is not available, the Alberta Healthy Living Program will arrange testing
with patient for those who require screening. If your patient has cognition difficulties, provide a copy of the
Montreal Cognitive Assessment test results, if available.
Cardiovascular
Metabolic
Respiratory
Musculoskeletal Neurological Mental Health
Blood Disorder
Dyslipidemia
Asthma
Arthritis
MS
Anxiety
CAD
Fatty Liver
COPD
Fibromyalgia
Neuropathy
Depression
MI
Pre-Diabetes
Sleep Apnea
Osteopenia
Parkinson’s
CHF
Obesity
Osteoporosis
Electrical Abnormalities
Diabetes Type 1
Total Hip Replacement
Hypertension
Diabetes Type 2
Total Knee Replacement
Stroke
Other chronic condition(s) not listed above:
Valve Disease
* List or attach any information
that may affect consultation / care
Concern
Explanation
Language barrier
Physical limitation(s) or fall risk
Cognitive concerns
Social / Psychological
Economic
20120 (2015-11)
Page 2 of 2