Registration form First name * Last name * Date of birth * Gender * Please select Male Female Non-binary A different term Prefer not to say Address * Email address * Phone number * Are you of Aboriginal or Torres Strait Islander origin? * Please select No Yes, Aboriginal Yes, Torres Straight Islander Yes, Aboriginal and Torres Straight Islander Are you pregnant? * Please select Yes No What is your reason for signing up? * Please select Diabetes or pre-diabetes Heart disease (eg. high blood pressure, heart failure, blocked arteries) Stroke or nerve problems Cancer rehabilitation Musculoskeletal conditions (eg. arthritis, osteoporosis) Respiratory conditions (eg. Asthma, COPD) Kidney or liver conditions Weight loss Mental health Chronic pain Other (Please specify) Please specify * Is an interpreter or National Relay Service required? * Please select No Interpreter required National Relay Service required Language * How did you hear about the Better Health Coaching Service? * By submitting this form you agree to our terms and conditions and privacy policy. You may receive emails from us and can opt out at any time. Submit × You are Inelligible Do you wish to continue?
