Referral Form - Shape Up 4 Life Wiltshire

Title*

Name*

Firstname Lastname

Address*

Address line 1 Address line 2 City Post code

Mobile*

Landline

Email address*

Date of birth*

Gender*

Female
Male
Not stated/ other

GP Surgery

Height (metres)*

Weight (kg)*

BMI

Physical Activity Readiness - Questionnaire (PAR-Q)

Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life For most people physical activity should not pose any problem or hazard. PAR-Q is designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is the best guide in answering these few questions.

Has your doctor ever said that you have a bone or joint problems?*

Yes
No

Has your doctor ever said that you currently have or have had a heart problem?*

Yes
No

Have you ever been diagnosed with epilepsy?*

Yes
No

Have you ever been diagnosed with high blood pressure?*

Yes
No

Have you ever been diagnosed with diabetes?*

Yes
No

Do you suffer from any respiratory illnesses (including asthma)?*

Yes
No

Have you ever been diagnosed with dietary illness?*

Yes
No

Have you ever felt pain in your chest at rest or when you do physical exercise?*

Yes
No

Are you currently taking any medication?*

Yes
No

In the past year, have you had any major illness or surgery?*

Yes
No

Do you ever lose your balance because of dizziness or lose consciousness?*

Yes
No

Are you pregnant?*

Yes
No

Do you know of any other reason why you should not participate in a physical activity programme?*

Yes
No

If you have selected yes to any of the above then you can either Download the GP referral form, fill it out and bring it with to participate in the main programme or you can register for ShapeUp4Life open with no need for medical referral and no waiting list.

Please download the GP referral form here

Select which course you would like to sign up for from the dropdown:

*

Consent*

Consent Provided

Solutions4health would encourage you to provide your consent in order that we can process data and information about you. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at (www.solutions4health.co.uk/contact-us).

Sign Up

Sign Up Form

Physical Activity Readiness - Questionnaire (PAR-Q)