Active Lifestyles Health Professionals Referral Form

1. Personal Details

You can refer a patient to the programme using the form below, or for more info contact the Healthy Communities team on: 01224 507701 or email: activelifestyles@sportaberdeen.co.uk

Patient Contact Details: *

Forename	*
Preferred name	*
Surname	*
Date of birth	*

Does the patient have a physical or mental health condition or illness lasting or expected to last 12 months or more?

Yes
No
Prefer not to say

Does the patient consider themselves to have a disability?

Yes
No
Prefer not to say

Do the patient consider themselves to have a caring role? (this is anyone of any age who helps a relative, friend or neighbour who cannot manage without their support and has taken on an unpaid caring role in addition to their existing commitments)

Yes
No
Prefer not to say

Address: *

Address 1	*
Address 2	*
Town	*
Postcode	*
Telephone Number	*
Mobile Number	*
Email address	*

Emergency contact *

Name	*
Telephone Number	*
Relationship to participant	*

Referrer contact details: *

Name of referrer	*
Job role	*
Contact role	*
Contact email	*

Has the patient attended an NHS Rehabilitation Programme?

Patient Health Details (does the patient have any of the medical conditions listed below?) *

	Yes	No
Heart Conditions (e.g. heart attack)	Heart Conditions (e.g. heart attack) Yes	Heart Conditions (e.g. heart attack) No
Breathing conditions (e.g. asthma)	Breathing conditions (e.g. asthma) Yes	Breathing conditions (e.g. asthma) No
Diabetes	Diabetes Yes	Diabetes No
Neurological condition (e.g. stroke)	Neurological condition (e.g. stroke) Yes	Neurological condition (e.g. stroke) No
Epilepsy	Epilepsy Yes	Epilepsy No
Surgery (e.g. joint replacement)	Surgery (e.g. joint replacement) Yes	Surgery (e.g. joint replacement) No
Hearing / visual difficulty	Hearing / visual difficulty Yes	Hearing / visual difficulty No
Cognitive impairment (e.g. dementia)	Cognitive impairment (e.g. dementia) Yes	Cognitive impairment (e.g. dementia) No
Bone, muscle, joint condition (e.g. osteoporosis)	Bone, muscle, joint condition (e.g. osteoporosis) Yes	Bone, muscle, joint condition (e.g. osteoporosis) No
Mental health condition	Mental health condition Yes	Mental health condition No
Cancer	Cancer Yes	Cancer No

Other relevant information

Health screening questionnaire *

	Yes	No
Has the participant’s doctor ever said they have a heart condition and should only do physical activity recommended by a doctor?	Has the participant’s doctor ever said they have a heart condition and should only do physical activity recommended by a doctor? Yes	Has the participant’s doctor ever said they have a heart condition and should only do physical activity recommended by a doctor? No
Does the participant feel pain in their chest when they do physical activity?	Does the participant feel pain in their chest when they do physical activity? Yes	Does the participant feel pain in their chest when they do physical activity? No
In the past month, has the participant had pain in their chest when they are not doing physical activity?	In the past month, has the participant had pain in their chest when they are not doing physical activity? Yes	In the past month, has the participant had pain in their chest when they are not doing physical activity? No
Does the participant lose their balance because of dizziness or do they ever lose consciousness?	Does the participant lose their balance because of dizziness or do they ever lose consciousness? Yes	Does the participant lose their balance because of dizziness or do they ever lose consciousness? No
Has their doctor ever said that they have had a stroke?	Has their doctor ever said that they have had a stroke? Yes	Has their doctor ever said that they have had a stroke? No

How active is the patient currently? E.g. activity could be walking around the block daily/gardening or housework/attending an exercise class once a week

Reason for referring this patient

Privacy Notice *

	Yes	No
The patient has been informed about the programme and wishes to join an exercise group	The patient has been informed about the programme and wishes to join an exercise group Yes	The patient has been informed about the programme and wishes to join an exercise group No
The patient has agreed to their information being stored securely and accessed confidentially by the Exercise Instructors	The patient has agreed to their information being stored securely and accessed confidentially by the Exercise Instructors Yes	The patient has agreed to their information being stored securely and accessed confidentially by the Exercise Instructors No
The patient has consented to receiving email updates from Sport Aberdeen (they can withdraw consent at any time by contacting activelifestyles@sportaberdeen.co.uk or 01224 507701)	The patient has consented to receiving email updates from Sport Aberdeen (they can withdraw consent at any time by contacting activelifestyles@sportaberdeen.co.uk or 01224 507701) Yes	The patient has consented to receiving email updates from Sport Aberdeen (they can withdraw consent at any time by contacting activelifestyles@sportaberdeen.co.uk or 01224 507701) No
The patient understands that information will be held at Sport Aberdeen for the purposes of my participation in the programme	The patient understands that information will be held at Sport Aberdeen for the purposes of my participation in the programme Yes	The patient understands that information will be held at Sport Aberdeen for the purposes of my participation in the programme No
The patient has been signposted to the Sport Aberdeen Privacy Notice www.sportaberdeen.co.uk/sport-aberdeen/privacy-policy	The patient has been signposted to the Sport Aberdeen Privacy Notice www.sportaberdeen.co.uk/sport-aberdeen/privacy-policy Yes	The patient has been signposted to the Sport Aberdeen Privacy Notice www.sportaberdeen.co.uk/sport-aberdeen/privacy-policy No