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Active North Yorkshire - Harrogate District - Online Referral Form

Active Health - MSK Trailblazer

Therapeutic exercise on referral for chronic MSK issues

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

Cognitive impairment (such as autistic spectrum disorder or resulting from a head injury)

Specific learning disability (such as dyslexia)

Long standing illness or health condition (such as cancer, HIV, diabetes or epilepsy)

General learning disability (such as Downs Syndrome)

Mental health condition (such as depression or schizophrenia)

Deaf or serious hearing impairment

Blind or serious visual impairment

Other type of disability

Medical conditions (tick all that apply)

Arthritis (moderate osteoarthritis/rheumatoid)

Asthma (Chronic)

Cancer - Bladder

Cancer - Breast

Cancer - Cervical

Cancer - Colorectal

Cancer - Head and Neck

Cancer - Lung, Trachea and Bronchus

Cancer - Melanoma

Cancer - Non-Hodgkin Lymphoma

Cancer - Other

Cancer - Prostate

Cancer - Unknown

Cancer - Uterine

CHD

Chronic Fatigue/ME

Claudication

COPD

COVID-19

CVD event post 6 months

CVD event within last 6 months

Depression (clinical)

Diabetes (Type 1)

Diabetes (Type 2 Insulin treated)

Diabetes (Type 2)

Fibromyalgia

HIV symptomatic

Hyperlipidaemia (controlled)

Hypertension (controlled)

IGT/IFG

Joint Replacement

Long COVID

Mental health condition

Motor Neuron Disease (stable)

Multiple Sclerosis (stable)

Musculoskeletal (pain/injury)

Obese (30-39.9)

Osteoporosis

Overweight (25-29.9)

Parkinson's Disease (stable)

PVD

Recent Surgery

Severely Obese (40+)

Stress/Anxiety

Stroke/TIA

Medication (tick all that apply)

Alendronate

Amlodipine

Aspirin

Beclomethasone

Bendroflumethiazide

Bisoprolol

Chondroitin

Citalopram

Digoxin

Fluoxetine

Furosemide

Gliclazide

Glucosamine

GTN Spray

Insulin

Isosorbide Mononitrate

Lansoprazole

Metformin

Methotrexate

Metoprolol

Mirtazapine

Orlistat

Perindopril

Pravastatin

Prednisolone

Ramipril

Rivaroxaban

Salbutamol

Simvastatin

Spironolactone

Tramadol

Ventolin

Warfarin

Other Medication

GP Practice *

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 MSK Trailblazer Hub, 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 will never share it without permission. I agree to be contacted by letter, email, telephone, and SMS text message.

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