Recommended ‘Exercise Referral’Form
Part A – Health Professionals Consent (To be completed by the registered referring health professional i.e. GP/Nurse/Community Health Trainer/Physiotherapist).
Patient’s name: ………………………......
I recommend the above patient to participate in an exercise programme of moderate intensity. I confirm that I have assessed this patient and to my knowledge there is no medical reason why he/she should not participate in a recommended exercise programme. I confirm that I have discussed the scheme with the patient.
Name of referring health professional …………………………......
Signed ………………………………………...... Date: ......
Part B – Patients Consent (To be completed by the patient before attending the recommended scheme).
I consent to participating in a structured exercise programme of low to moderate intensity, the nature and purpose of which has been explained by my GP/referring Health Professional. I consent to the release of relevant medical information about myself to a Qualified Exercise Referral Instructor. Information obtained will be treated as confidential, although it may be used anonymously for statistical or research purposes.
Signed……………………………………..Date ofBirth……...... Date……...... Telephone:(Day)………………………….. (Evening)……………………………
Email………………………………………….Postcode……………………………
Part C – Medical Information (All questions to be completed by the registered referring health professional i.e. GP/Nurse/Community Health Trainer/Physiotherapist).
1.Objective (s) of the referral (tick as many boxesasapply):ImproveoverallhealthReduce bloodpressure
ImprovemobilityReducestress/anxiety/depression
ImprovemusclestrengthLoseweight
ImproveFlexibilityImproveRespiration
OsteoporosispreventionFallsprevention
Cycling forHealthCancerRehabilitation
Other (please state): ………………......
2. Main Reason For Referral: ......
......
3.Number of visits that your patient has made to their GP in the 12 weeks prior to completingthisreferralform(pleasegiveapproxifnotknown):…………......
4.Baselinemeasures:
5.Relevant Medical History:………………....…………………………………………………......
...... 6.Medicationandpossiblesideeffects:......
…………………………………………………………………………………………......
......
Use the space below to add further comments (e.g. Language and culture): ...... ……………
………………………………………………………………………………………...... ……
………………………………………………………………………………………...... ……
Footnote – Once this form has been completed and signed by your GP or referring health professional you have 2 options.
Option 1:- Your GP/Nurse/Community Health Professional can send your referral form direct to the centre of your choice. The centre will then contact you to arrange your appointment or
Option 2:- You keep your referral form and contact the centre of your choice direct on the detailsbelow.
If your referral is just for CYCLING4HEALTH, please phone 01453 754322 to find out how to access thescheme.
B&F Fitness: 01453 843671 –
Fifth Dimension – 07922 873934 –
Maidenhill Sports & Dance Centre – 01453 754508-
The Pulse Dursley - 01453 546441 –
Richmond Painswick Wellness Spa – 01452 810211 –
Stratford Park Leisure Centre - 01453 766771 -
Thomas Keble Sports Centre – 01453 754508-
If you require any further information please contact the Healthy Lifestyles Co-ordinator on 07875 793158 or Sport & Health Development on 01453 754508