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HELP (Healthy Exercise and Lifestyle Programme) Exercise Referral Form Name: ~[Title] ~[Forename] ~[Surname] D.O.B: ~[Date Of Birth] Gender: ~[Sex] Address: ~[Patient Address Line 1], ~[Patient Address Line 2], ~[Patient Address Line 3], ~[Patient Address Line 4] Tel No: ~[Telephone Number] Preferred site: Washington Puma Crowtree Seaburn Houghton Bunny Hill Raich Carter Details / reason for referral: Low risk: Ante natal Anxiety/stress CHD prevention Depression Motivation Muscle injury (currently (no cardiac (mild/stable) (no co-morbidities) exercising) symptoms) Overweight Osteoporosis Post natal Sedentary/unfit Smoker Prevention (no complications) (no co- (no respiratory (BMI >25-29.9) morbidities) problems) Moderate risk: Arthritis Asthma Falls Prevention Hypertension Intermittent Claudication (no cardiac (mild/well (no fractures) (not on B Blockers) (no cardiac symptoms) symptoms) controlled) Obesity (BMI > 30-39.9) Osteoporosis Surgical preparation / recovery (no cardiac symptoms) (non cardiac) High risk: Angina Asthma CABG/PCI Cardiac Diabetic Falls Prevention (stable) (moderate) (completed phase (completed (stable) (fractures, frail) III) phase III) Heart Hypertension Obese (BMI Sedentary/unfit Stroke Attack (stable) >40) (no co- (completed morbidities) phase III) Additional relevant information: PLEASE NOTE: Patients who have a history of cardiac problems may need to be re-assessed by a cardiac rehabilitation professional before being accepted onto the scheme. To ensure that your patient is suitable for HELP, please complete the section below (please mark all that apply. Heart attack Yes No If Yes, have they completed Phase III Yes No If No, refer to cardiac service Angina Yes No If Yes, is the condition stable Yes No If No, refer to cardiac service CABG/PCI: Yes No If Yes, have they completed Phase III Yes No If No, refer to cardiac service service Awaiting cardiac investigation / procedure: Yes No If Yes, refer to cardiac service Patient currently taking medication for: Angina Arthritis Asthma Cancer Cardiac Cholesterol problems Depression Diabetes Epilepsy Heart Attack Hypertension Muscle injury Osteoporosi Stress/Anxiety Stroke Weight Loss s Other: * Please indicate if this referral is being used as an alternative to medication Yes No If Yes, please say what type of drug you would have prescribed: * OPTIONAL – Please delete any of the following activities that you think are unsuitable for this person (this section only to be completed if the referring agent feels confident in their knowledge of the variety of exercises/activities available – if not please leave blank): Low-impact Aerobics Aerobic Dance Aquafit Badminton Bowls Brisk Walking Cross Training (gym) Heart Smart Class Line Dancing Outdoor Cycling Recumbent Bike (gym) Rowing (gym) Soft Tennis Stepper (gym) Step Aerobics Strength programme (gym) Swimming Table Tennis Toning programme (gym) Treadmill Upright Bike (gym) Walking Weights Yoga I agree for the above information to be passed onto the Community Fitness Officer for the Healthy Exercise and Lifestyle Programme. I understand that I am responsible for monitoring my own responses during exercise and will inform the instructor of any new or unusual symptoms, I will also inform the instructor of any changes in my medication, the result of any investigations or treatments. Patient’s signature: Date: Please print name: I confirm that the above named person has met the approved criteria (see protocol document) for inclusion in the HELP scheme. Referring Agent’s Signature: Date: Please print name and title: March 2006 version Updated April 2007 PATIENT SHOULD BE GIVEN A COPY OF THE HANDOUT. THESE ARE AVAILBLE TO ORDER FROM MOPIL.
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