HELP (Healthy Exercise and Lifestyle Programme) Exercise Referral Form by UC16FL9k


									                              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

Awaiting cardiac investigation / procedure: Yes                No         If Yes, refer to cardiac service

Patient currently taking medication for:
 Angina                     Arthritis                     Asthma                       Cancer                      Cardiac                      Cholesterol
 Depression                 Diabetes                      Epilepsy                     Heart Attack                Hypertension                 Muscle
 Osteoporosi                Stress/Anxiety                Stroke                       Weight Loss
 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

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