SLL GP Referral Please note, this form is for patients in Stevenage, North Hertfordshire and Rutland. Those looking to join Central Bedfordshire’s scheme, please disregard this form and contact the centres directly. First name: Surname: Gender: DOB: Mobile: Daytime tel: Address: GP: GP practice: Please if the patient has any of the following contraindications to physical activity, if yes the patient will not be eligible to join the scheme. Unstable Angina Uncontrolled Diabetes Recent acute soft tissue injury Systollic Blood Pressure 180mm/Hg at rest Diastolic Blood Pressure 100mm/Hg at rest Uncontrolled Tachycardia 100bpm at rest Unstable or acute heart failure Reason for referral: Inactive AND please tick at one of these other criteria Controlled Hypertension Osteoporosis Smoker Controlled Diabetes Unhealthy Weight (BMI>28) Stroke Osteoarthritis/Rheumatoid Arthritis High Cholesterol Levels Cancer Mild to Moderate Mental Health Condition Musculoskeletal Rehabilitation Heart Disease COPD Back Pain (please state) Medication: 1. 2. 3. 4. 5. 6. Blood Pressure: Systolic: Diastolic: Additional comments/ Relevant conditions:
SLL GP Referral Please note, this form is for patients in Stevenage, North Hertfordshire and Rutland. Those looking to join Central Bedfordshire’s scheme, please disregard this form and contact the centres directly. First name: Surname: Gender: DOB: Mobile: Daytime tel: Address: GP: GP practice: Please if the patient has any of the following contraindications to physical activity, if yes the patient will not be eligible to join the scheme. Unstable Angina Uncontrolled Diabetes Recent acute soft tissue injury Systollic Blood Pressure 180mm/Hg at rest Diastolic Blood Pressure 100mm/Hg at rest Uncontrolled Tachycardia 100bpm at rest Unstable or acute heart failure Reason for referral: Inactive AND please tick at one of these other criteria Controlled Hypertension Osteoporosis Smoker Controlled Diabetes Unhealthy Weight (BMI>28) Stroke Osteoarthritis/Rheumatoid Arthritis High Cholesterol Levels Cancer Mild to Moderate Mental Health Condition Musculoskeletal Rehabilitation Heart Disease COPD Back Pain (please state) Medication: 1. 2. 3. 4. 5. 6. Blood Pressure: Systolic: Diastolic: Additional comments/ Relevant conditions:
SLL%20GP%20Referral%20Hitchin.docx