Trafford Leisure Physical Activity Referral Form (To be completed by referring Person being referred Title Name Address Contact number Landline: Mobile: Email DOB Inactive / sedentary Moderately active Current level of Physical Activity Low levels of activity Active being undertaken Physical Activity Referral Falls prevention Please tick which programme you think the referral is best Cancer rehabilitation Cardiac rehabilitation suited to Family Activity Referral Reason for being referred Is the referral self-funded or Self-funded Agent funded funded through (Please tick) Height Date Weight Date Measurements BMI Date Blood Date Pressure Anxiety / Hypertension Depression Severe Mental Illness Chronic Fatigue Cardio Vascular disease Syndrome Epilepsy Fibromyalgia Relevant medical conditions Learning Disability Musculoskeletal that we should be aware of Post Bariatric surgery (Please tick all that are disorders Sleep disorders applicable) Pre Bariatric Other surgery Type 1 Diabetes Type 2 Diabetes Asthma Medication and reason for taking
Trafford Leisure Physical Activity Referral Form (To be completed by referring Person being referred Title Name Address Contact number Landline: Mobile: Email DOB Current level of Physical Activity being undertaken Inactive / sedentary Low levels of activity Moderately active Active Please tick which programme you think the referral is best suited to Physical Activity Referral Cancer rehabilitation Family Activity Referral Falls prevention Cardiac rehabilitation Reason for being referred Is the referral self-funded or funded through (Please tick) Self-funded Agent funded Measurements Height Date Weight Date BMI Date Blood Pressure Date Relevant medical conditions that we should be aware of (Please tick all that are applicable) Anxiety / Depression Chronic Fatigue Syndrome Fibromyalgia Musculoskeletal disorders Pre Bariatric surgery Type 1 Diabetes Type 2 Diabetes Asthma Hypertension Severe Mental Illness Cardio Vascular disease Epilepsy Learning Disability Post Bariatric surgery Sleep disorders Other Medication and reason for taking