Referral for Exercise - Details of Patient
This form can be used to refer patients onto the Liverpool Exercise for Health scheme and can be used in one of 3 ways subject to the patients preference:
- Completed in full and e-mailed to the patients preferred Lifestyles Centre. (see over) This will allow the centre to contact the patient direct to arrange their first appointment.
- Complete Section 1 and e-mail to the preferred Lifestyles centre if either patient or practice has concerns regarding the confidentiality of information being e-mailed. However, the form must be fully completed and handed to the patient to present in person at their subsequent appointment at the Lifestyles centre.
- Completed in full, printed and given to the patient. In this case the patient will be responsible for making contact with their preferred Lifestyles centre. Evidence suggests that some individuals may not make contact with Lifestyles once they leave the surgery / care centre and lose an opportunity to participate in the programme.
Section 1. / Referral for Exercise – Patient Contact Details
Surname: / First Name: / Date of Birth
Contact Telephone Number: / Alternative
Contact Number:
Please state when you prefer to be contacted: / DAY / TIME
Please advise the patient, that if they have not received a call within 2 working days they can call in person at the Lifestyles centre to where they are referred or they can call 0151 233 5433.
The patient needs to be aware that Lifestyles calls may show as ‘withheld’ numbers.
------
The GP/Nurse certifies that he/she is not aware of any condition that will preclude the patient from participating in an exercise programme. I refer this patient to the Liverpool Exercise for Health scheme under the terms and conditions set out in the information booklet.
GP/Nurse Name: / GP Practice Name:
Practice Telephone Number: / Practice Number:
Section 2. / Referral for Exercise – Patient Details
Reason for Exercise Referral:
1 / Hypertension / 6 / Inactive/
Sedentary / 11 / Back Pain / 16 / Blood Pressure
2 / Diabetes / 7 / Asthma / 12 / General Fitness / 17 / Cholesterol
3 / Weight Reduction / 8 / Osteoarthritis / 13 / Stroke / 18 / Angina
4 / Stress/Anxiety / 9 / Other CHD risks / 14 / Sciatica / 19 / Other not listed
5 / Osteoporosis / 10 / Depression / 15 / Post M.I.
Relevant medical conditions: (not indicated in Reason for Exercise referral above)
……………………………………………………………………………………………….continued over
Patient Height: / Blood Pressure:
/mmHg
Patient Weight: / Resting Pulse:
/bpm
Current medication:
1 / 4
2 / 5
3 / 6
Section 3. / What best describes your racial origin?
(Please mark with ‘X’ in relevant box)
Asian British / Caribbean / Yemeni / White and Black Caribbean
Indian / African / Gypsy / White and Black African
Pakistani / Nigerian / Traveller / White and Asian
Bangladeshi / Somali / White British / Other mixed background
Other Asian background / Other Black Background / White Irish / Prefer not to say
Black British / Chinese / Other white background / Information not obtained
Do you consider yourself disabled? / YES / NO / Prefer not to say
Exercise for Health Centres
Lifestyles Alsop / / 0151 233 5433
Liverpool Aquatics / / 0151 233 5433
Lifestyles Austin Rawlinson / / 0151 233 5433
Lifestyles Ellergreen / / 0151 233 5433
Lifestyles Croxteth / / 0151 548 3421
Lifestyles Everton / / 0151 233 5433
Lifestyles Garston / / 0151 233 5433
Lifestyles Millennium / / 0151 233 5433
Lifestyles Peter Lloyd
Lifestyles Park Road /
/ 0151 233 5433
0151 233 5433
Lifestyles Walton / 0151 523 3472
Kensington Community Centre / / 0151 261 9598
BNENC – Sport & Activity Centre / / 0151 288 8403
S:\Customer Contact\Memberships\Health Schemes\Excercise for Health GP Referral Form April 2013 version 5.doc
Page 1 of 2