referral form

weight off workshop
Active Life
– GP referral
lCoronary
heart disease
lDepression lDiabetes lCancer
lOrtho/musculoskeletal
01293 585333
Call: 01293 585318
What is
– GP referral
Want to lose weight and improve your
physical activity?
Weight Off Workshop or WoW is a weight loss course
for adult patients in Crawley, with a BMI (Body Mass
Index) over 28.
What is WoW?
• FREE – 12 week weight management course, to
encourage weight loss and to improve your fitness
and general wellbeing
• EASY – choice of classes to attend each week –
morning, afternoon and evening at a variety of
venues across the town
• SIMPLE – No set diet or calorie allocation – we
encourage making changes to your existing eating
and activity levels that you can continue once you
have successfully completed the course
• FRIENDLY – Weekly, group, 1½ hour sessions
– weigh-in, topical discussion and light physical
activity with qualified advisors
• SUPPORTIVE – post-course help and activity
programme once you have completed the course –
fees apply
How do I get referred?
• Ask your practice nurse or GP to complete the attached form and return it to Crawley Wellbeing
What happens next?
•
Active Life
– GP referral
• What – 12 week gym programme
where patients can exercise
independently
• Where – K2 Crawley
• When – Active Life sessions vary but
are available daytime, evening and
weekends and are supported by fully
qualified staff
• Why – cardiac disorders,
rehabilitation, diabetes, stroke,
anxiety and stress, back pain,
respiratory problems and weight
related illnesses
• Who – adults aged 16+ registered
with a GP in Crawley
• How – ask your GP or healthcare
professional to complete and sign the
form and return it to the
address below
• Cost – £3.40 per session.
Concessionary and discounted rates
are available
• Contact – 01293 585333.
Once we have received your completed and signed form we will contact you as soon as possible to get you going as quickly as we can – there is no waiting list.
Further information available
crawley.westsussexwellbeing.org.uk
or join www.facebook.com/ crawleyChange4Life
Active Life, Crawley Wellbeing, K2 Crawley
Pease Pottage Hill, Crawley RH11 9BQ
WoW / Exercise referral
Preferred activity options (please tick all apply)
Active Life (gym based)
r
Weight off Workshop
r
To be completed by the health professional
Where did you find out about the referral
programme?
Crawley Wellbeing r
GP Surgery
r
Hospital
r
Local paper
r
CBC website
Other health
professional
Word of mouth r
r
r
Client’s name:
Gender:
Male r
Female r
Ethnicity:
White British
r Mixed race
r
Asian/Asian British r Black/Black British r
Chinese
r
Other (please state) r
Date of birth
SmokerRegular r Occasional rNever r Address (including neighbourhood and postcode):
Emergency contact: name and phone number
Please tick if you do not wish to be
contacted by a Wellbeing Advisor r
Current BP and resting heart rate
BMI 28+ (please state BMI) Main reason for referral
Please tick all applicable reasons for referral,
ensuring that medications are recorded. Other
conditions and related medications should be
recorded in the appropriate box (please include
group of drugs, chemical name and brand name)
Other conditions (tick all that apply)
Stress/Anxiety/Depression
r
Diabetes - Type 1
r
Diabetes - Type 2
r
Coronary artery high risk factors
r
Ortho/musculoskeletal
r
Chronic obstructive airways disease
r
Osteoporosis
r
Cancer
r
Controlled Hypertension <160/100
r
Back pain
r
Post-operative conditioning
r
Pre-operative conditioning
r
Learning disability
r
Other
r
Please provide details, including medication given,
for the above condition(s)
Contact telephone (daytime and evening):
Email
Wellbeing Services
Declarations
Small changes today for a better
tomorrow
Health professional’s name and job title
• Healthy
Eating advice
• Increase activity
• Stop smoking
• Reduce alcohol
• Healthy mind
Signature
Email
Which surgery is the patient registered with?
Contact number
I have read and understood the Referral Scheme
operational manual and I confirm that this
patient meets the criteria for participating in any
of the following referral programme(s):
Activity options (tick all that are acceptable)
Active Life (gym based) r
Weight off Workshop (all components) r
• Alcohol support
• Health walks
• Tai chi
• Older people’s stength and
stability classes
• Signpost for practical
assistance, sexual health,
dementia services and
much more!
• Wellbeing
MOTs
• NHS Health
Check
FREE Mini MOTs
Date completed
I know of no reason why this patient is unfit to
exercise
rAgree
• Get healthy
• Get active
• Get support
rDisagree
(This statement couples with the recommendation
from the Medical Defence Union)
How old are you on the inside?
Why not come along to see one of our friendly Wellbeing
advisors to find out!
Also discover your hydration levels, fat %, internal fat and
bone mass with advice, support and motivation offered to
improve your readings.
Book a free appointment with one of our advisors
today, call us on: 01293 585317
or email us at: [email protected]