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Referred by

Name of Referral

Email Address

Address

Phone Number

Reason for Referral

CHD Risk Factors

Mild Anxiety/Depression

High BMI/Overweight

High Blood Pressure

Arthritis

Other

Please give further detail on the above

Sessions of Interest

Preferred means of contact

Email

Phone

Either

Has Your Doctor Ever Said you have a heart condition or high blood pressure?

Yes

No

Do you feel pain in your chest at rest, during daily activity or when doing physical activity?

Yes

No

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

No

Have you ever been diagnosed with a chronic medical condition?

Yes

No

Are you currently taking prescribed medication for a chronic condition?

Yes

No

Do you currently have (or in the past 12 months) have a bone, joint, soft tissue injury that may be made worse by physical activity?

Yes

No

Has your doctor ever said that you should only do medically supervised activity?

Yes

No

Language Preference for Call Back

English

Welsh

I confirm I have consent to make this referral

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If answered yes to any of the above, please provide more details.

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