Stockports number one fitness and leisure provider

Physical Activity Referral in Stockport (PARiS) is the Exercise Referral scheme delivered by Life Leisure, designed to help inactive people with chronic mild to moderate medical conditions become and stay more physically active, whilst benefiting and improving their health.

I’m a health professional and I want to refer someone:

Patient’s details

Prefix ^*
First Name ^*
Surname ^*
Home Address ^*
Town
County
Postcode ^*
Telephone / Mobile ^*
Email
Date of Birth (dd/mm/yyyy)^*
Gender ^*
Medical conditions (please select all that apply)
Angina (current) (stable)Angioplasty / StentAortic valve replacement (AVR)Arthritis (moderate osteoarthritis/rheumatoid)
Asthma (Chronic)Atrial fibrillationCABGCancer - Bladder
Cancer - BreastCancer - CervicalCancer - ColorectalCancer - Head and Neck
Cancer - Lung, Trachea and BronchusCancer - MelanomaCancer - Non-Hodgkin LymphomaCancer - Other
Cancer - ProstateCancer - UterineCHDChronic Fatigue/ME
ClaudicationCOPDCOVID-19CVD event post 6 months
CVD event within last 6 monthsDepression (clinical)Diabetes (Type 1)Diabetes (Type 2 Insulin treated)
Diabetes (Type 2)FibromyalgiaHIV symptomaticHyperlipidaemia (controlled)
Hypertension (controlled)ICD / Pacemaker fittedIGT/IFGJoint Replacement
Long COVIDMental health conditionMotor Neuron Disease (stable)Multiple Sclerosis (stable)
Musculoskeletal (pain/injury)Myocardial infarction (MI)Obese (30-39.9)Osteoporosis
Overweight (25-29.9)Parkinson's Disease (stable)Post SurgerySeverely Obese (40+)
Stress/AnxietyStroke/TIA
Other medical conditions

Consent Please read and confirm to the statements below

I understand that I am completing a referral request to the PARiS scheme. Please note that completion of this form indicates consent to this information being passed on to and recorded by Life Leisure. I understand that my details will be stored on a secure database system in an appropriate confidential manner. I agree to be contacted by letter, email, telephone and SMS text message. I understand that by completing a referral request does not indicate I am automatically accepted onto the PARiS service and eligibility will be discussed with the PARiS Coach. Please note that although you have completed the self-referral form, we still may request additional information from your GP for certain medical conditions. This would be discussed with you before a request is made.

Exercise Referral

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