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Cymraeg
Referral Form
Referred by
Self-Referral
GP
Health and Wellbeing professional
Name of Referral
Email Address
Address
Phone Number
Reason for Referral
CHD Risk Factors
Mild Anxiety/Depression
High BMI/Overweight
High Blood Pressure
Arthritis
Other
Please give further detail on the above
Sessions of Interest
Preferred means of contact
Email
Phone
Either
Has Your Doctor Ever Said you have a heart condition or high blood pressure?
Yes
No
Do you feel pain in your chest at rest, during daily activity or when doing physical activity?
Yes
No
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?
Yes
No
Have you ever been diagnosed with a chronic medical condition?
Yes
No
Are you currently taking prescribed medication for a chronic condition?
Yes
No
Do you currently have (or in the past 12 months) have a bone, joint, soft tissue injury that may be made worse by physical activity?
Yes
No
Has your doctor ever said that you should only do medically supervised activity?
Yes
No
Language Preference for Call Back
English
Welsh
I confirm I have consent to make this referral
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If answered yes to any of the above, please provide more details.