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Active North Yorkshire - Harrogate District - Online Referral Form

Active Health - Healthy You

Free service for adults or children living with obesity. The Healthy You service includes free access to physical activity and lifestyle classes.

Inclusion Criteria

Aged four years or above.
BMI equal to or greater than 30 (or 25 with exception) or children at or above 91st centile for BMI (where centile/BMI is known). Exceptions will be made for children and young people with no centile/BMI measure available.
Resident or registered to a GP practice in the Harrogate district.

Exclusion Criteria

Have a diagnosed eating disorder.
Have a significant unmanaged co-morbidity.
Have had bariatric surgery in the last 2 years.

Fields marked with an * are required fields.

Your personal details

First name *

Surname *

Address *

Town *

County *

Postcode *

Please provide either a mobile number or a landline number *

Mobile phone number

Landline phone number

Email *

Date of birth *

Gender *

Ethnicity *

First Language *

Employment Status *

Height (cm) *

Weight (kg)*

Emergency Contact Name *

Emergency Contact Number *

Relationship To Patient

Emergency Contact Email Address

Disabilities (tick all that apply)

Prefer not to say

Unknown

No disability

Wheelchair user

Behaviour and Emotional

Hearing

Manual Dexterity

Memory or ability to concentrate, learn or understand (Learning Disability)

Mobility and Gross Motor

Perception of Physical Danger

Personal, Self Care and Continence

Speech

Sight

Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)

Other type of disability

Medical conditions (tick all that apply)

Alzheimer's disease

Angina

Ankle injury

Ankle pain

Arrhythmia

Asthma

At risk of falls

Atrial fibrillation

Bipolar

Bypass

Cancer - Bladder

Cancer - Breast

Cancer - Cervical

Cancer - Colorectal

Cancer - Lung

Cancer - Other

Cancer - Prostate

Cancer - Skin

Cardiac pacemaker fitted

Cerebral palsy

CHD

Chest Pain

Chronic Fatigue/ME

Claudication

COPD

COVID-19

Creutzfeldt - Jakob disease

CVD event post 6 months

CVD event within last 6 months

Dementia

Depression

Diabetes (Type 1)

Diabetes (Type 2)

Elbow injury

Elbow pain

Epilepsy

Fibromyalgia

Foot injury

Foot pain

Frontotemporal dementia

Hand injury

Hand pain

Heart failure

Heart valve disorder

Hip injury

Hip pain

Hyperlipidaemia

Hypertension

Insulin dependent Type 1 diabetes

Insulin treated Type 2 diabetes

Karsakoff syndrome

Knee injury

Knee pain

Lewy bodies

Long COVID

Lower back injury

Lung disorder

Motor neuron disease

Multiple sclerosis

Myocardial infarction (MI)

Neck injury

Neck pain

Non-Hodgkin lymphoma

Obese (30-39.9)

Osteoarthritis

Osteoporosis

Overweight (25-29.9)

Parkinson's disease

Partial elbow replacement

Partial hip replacement

Partial knee replacement

Partial shoulder replacement

Polymyalgia

Poor balance

Psychosis

Recent Surgery

Recurrent falls

Rheumatoid arthritis

Schizophrenia

Severely Obese (40+)

Shoulder injury

Shoulder pain

Stents

Stress/Anxiety

Stroke

TIA

Total elbow replacement

Total hip replacement

Total knee replacement

Total shoulder replacement

Type 2 diabetes controlled by diet

Upper back injury

Vascular dementia

Wrist injury

Wrist pain

Young onset dementia

Medication (tick all that apply)

Acarbose

ACE Inhibitors

AD-CAL

Adipine

Alendronate

Alpha Blockers

Amitriptyline

Amlodipine

Angiotensin II Receptor Blockers

Anti Platelets

Anti-Arrhythmics

Anti-Coagulants

Anti-diabetic drugs

Anxiolytics

Aropnorph

Aspirin

Atenolol

Atorvastatin

Azathioprine

Baclofen

Beclomethasone

Bendroflumethiazide

Beta Blockers

Biguanides

Bisoprolol

Calcium Channel Blockers

Carbimazole

Carvedilol

Cerazette

Cetirizine

Chemotherapy

Chondroitin

Citalopram

Clopidogrel

Clopidrogrel

Clozapine

Codeine

Co-drydamol

Digoxin

Dipeptidyl Peptidase 4

Diuretics

Doxazosin

Edoxaban

Escitalopram

Estradiol

Ferrous fumarate

Fibrates

Fluoxetine

Fluticasone

Furosemide

Gabapentin

Gliclazide

Glimepiride

Gliptins

Glucosamine

GTN

Ibuprofen

Indapamide

Insulin

Irbesartan

Isosorbide Mononitrate

Ivabradine

Lansoprazole

Lercanidipine

Levothyroxine

Lisinopril

Losartan

Medication related to cancer treatment

Metformin

Methotrexate

Metoprolol

Mirtazapine

Monoamine-Oxidase inhibitors

Naproxen

Nebivolol

Nitrates

Nurofen

Olanzapine

Omeprazole

Oral Anti-Coagulant

Orlistat

Paracetamol

Perindopril

Potassium Channel Activators

Pravastatin

Prednisolone

Propanolol

Provera

Quetiapine

Radiation Therapy

Ramipril

Ranitidine

Risperdal

Rivaroxaban

Rosuvastatin

Salbutamol

Seretide

Sertraline

Sildenafil

Simvastatin

Spironolactone

Sulphonylureas

Tamoxifen

Temazepan

Thiamine

Thiazolidinediones

Thyroxine

Tolterodine

Tramadol

Trospium

Venlalic

Ventolin

Warfarin

Zapain

Other Medication

GP Practice *

On Healthy You everyone is given a free 12-week gym and swim membership, to use as much as you would like, at any of our centres. We also offer a weekly exercise class (this is a low-level interval class combining some strength exercises and cardio). Please note if you opt for the class there may be a wait for a space. * I want to add the class and I understand there may be a wait for a space. I just want to gym/swim

Your preferred centre to attend

Reason for referral *

How did you hear about this service?

Comments

Consent

By providing your consent, you agree to Active North Yorkshire processing and storing your personal data for the purpose of your participation in the Active North Yorkshire – Active Health Scheme. I understand the information provided is essential to my application and I consent to this information being stored securely in accordance with the General Data Protection Regulations (GDPR – 2018). Personal data will only be used by Active North Yorkshire and healthcare partners, and it will not be shared with any other third parties. We will keep data safe and never share it without permission. I agree to be contacted by letter, email, telephone, and SMS text message.

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