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]
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