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Exercise Referral Scheme

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Exercise Referral Scheme If you would like to join the exercise referral scheme. please contact Exercise your GP or medical professional to gain clearance to exercise. You Referral will not be accepted onto the scheme without the completed form. Scheme www.sll.co.uk/exercise-referral First name: Surname: Gender: DOB: Mobile: Daytime tel: Address: Postcode: GP: GP practice: Please state if the patient has any of the following contraindications to physical activity, if yes the patient will not be eligible to join the scheme. Unstable Angina Uncontrolled Diabetes Recent acute soft tissue injury Systolic Blood Pressure 180mm/Hg at rest Diastolic Blood Pressure 100mm/Hg at rest Uncontrolled Tachycardia 100bpm at rest Unstable or acute heart failure Reason for referral: Inactive AND please tick at least one of these other criteria Controlled Hypertension Osteoporosis Smoker Controlled Diabetes Unhealthy Weight (BMI>28) Stroke Osteoarthritis/ Rheumatoid Arthritis High Cholesterol Levels Cancer Mild to Moderate Mental Health Condition Musculoskeletal Heart Disease COPD Rehabilitation Back Pain Other (please state) Medication: 1. 2. 3. 4. 5. 6. Blood Pressure: Systolic: Diastolic: Additional comments/ Relevant conditions: Healthcare Professional Declaration: I am not aware of any contra-indication to physical activity for this referred patient. I have explained the scheme to the patient and they have given consent for the sharing of relevant health information between the appropriate healthcare and exercise professionals, consenting to the above information being held on a database. All personal data provided will be held in accordance with GDPR. For more information, please view SLL’s Privacy Policy at reception, find it in the footer of our website at www.sll.co.uk or request for an email copy at [email protected] Print name: Sign: Date: Exercise If you would like to join the exercise referral scheme. please contact your GP or medical professional to gain clearance to exercise. You Referral will not be accepted onto the scheme without the completed form. Scheme www.sll.co.uk/exercise-referral Hertfordshire First name: Surname: Gender: DOB: Mobile: Daytime tel: Address: NORTH HERTS lifestyles LEISURE CENTRE stevenage Postcode: Maria Esson Pippa Watkins Chris Tillbrook GP: GP practice: Archers Gym, Hitchin Swimming Centre North Herts Leisure Centre Stevenage Arts & Leisure Centre Fishponds Road, Hitchin, Herts SG5 1HA Baldock Road, Letchworth, Herts SG6 2ER Lytton Way, Stevenage, Herts, SG1 1LZ [email protected] 01462 679 311 [email protected] 01438 579 379 [email protected] state if the patient 01462 has 437 any 111 of the following contraindications to physical activity, if yes the patient will not be eligible to join the scheme. Unstable Angina Uncontrolled Diabetes Recent acute soft tissue injury Systolic Blood Pressure 180mm/Hg at rest Diastolic Blood Pressure 100mm/Hg at rest lifestyles Rutland Uncontrolled Tachycardia 100bpm at rest Unstable or acute heart failure at knights Hayley Faulkner Hannah Walter Reason for referral: Inactive AND please tick at least one of these other criteria Royston Leisure Centre Knights Templar Sports Centre WoodcockControlled Road, Hypertension Royston, Herts SG8 7XT Weston Osteoporosis Way, Baldock, Herts SG7 6EY Smoker Controlled Diabetes [email protected] 01763 255 190 [email protected] 01462 631 300 Anneka Sherratt Unhealthy Weight (BMI>28) Stroke Osteoarthritis/ Rheumatoid Arthritis Huntsmans Drive, Oakham, LE15 6RP High Cholesterol Levels Cancer Mild to [email protected] Mental Health Condition 01572 490 030 Musculoskeletal Heart Disease COPD Bedfordshire Rehabilitation Back Pain Other (please state) Medication: Available from Spring 2020 Jo Kerrigan Sandra Ratuszynska 1. 2. Steppingley Rd, Flitwick, Beds, MK45 1TH Parkside Drive, Houghton Regis, Beds LU5 5PY 3. [email protected] 015254. 493 131 [email protected] 01582 866 141 5. 6. Blood Pressure: Systolic: Diastolic: Natalie Darnell Dan Stolworthy Lucy Gregory AdditionalSaxon Drive, comments/ Biggleswade, Relevant Beds SG18 conditions: 8SU Engayne Avenue, Sandy, Beds SG19 1BL Mentmore Rd, Leighton Buzzard, Beds, LU7 2AF [email protected] 01767433133 [email protected] 01767 681 872 [email protected] 01525 375765 Healthcare Professional Declaration: lifestyles I am not aware of any contra-indication to physicalat activitysilsoe for this referred patient. SamPrint Deards name: A Profession:nna Figliola Date: Stotfold Road, Arlesey, SG15 6XS Chestnut Avenue, Silsoe, Beds, MK45 4GP Patient informed consent: I have had the scheme explained to me, I agree to participate and give my consent for the sharing of relevant [email protected] information about 01462 myself 341 114 between the [email protected] healthcare 01525 and exercise860357 professionals. I consent to the above information being held on a database. All personal data provided will be held in accordance with GDPR. For more information, please view SLL’s Privacy Policy at reception, find it in the footer of our website at www.sll.co.uk or request for an email copy at [email protected] For more infomation about SLL’s Exercise Referral Scheme; visit www.sll.co.uk/exercise-referral Print name: Sign: Date:.
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