Barnsley Premier Leisure Online Referral Form

Barnsley Health Referral Scheme

12-week Health Referral Scheme is run by Barnsley Premier Leisure and aims to help reduce health risks through promoting physical activity as a long term and sustainable lifestyle change.

Fields marked with an * are required fields.

Details of the person being referred

First name *

Surname *

Address *

Town *

County *

Postcode *

Please provide either a mobile number or a landline number *

Mobile phone number

Landline phone number

Date of birth *

Gender *

Ethnicity *

GP Practices

Patient preferred centre to attend

Medical conditions (tick all that apply)

Alzheimer's disease

Angiogram

Angioplasty / Stent

Aortic valve replacement (AVR)

Arrhythmias

Asthma (Controlled)

At risk of falls

Atrial fibrillation

Back Pain

CABG

Cancer

COPD (Mild-Moderate)

COVID-19

CVD/CHD

Dementia

Diabetes (Type 1)

Diabetes (Type 2)

ETT / ECG

Fibromyalgia

Heart failure

Hypercholesterolaemia : >6.5mmmols

Hypertension >140/90 BUT <180/100 controlled under BP Plan

ICD / Pacemaker fitted

Joint Replacement

Learning Disabilities

Long COVID

LV function - good

LV function - moderate

LV function - poor

Mild Depression

Mild-moderate Anxiety/Stress

Multiple Sclerosis (stable)

Musculoskeletal (pain/injury)

Neurological

NSTEMI

Obese (30-39.9)

Osteoarthritis

Osteoporosis

Overweight (25-29.9)

Parkinson's Disease (stable)

Post surgery rehabilitation

Pre Surgery

Rheumatoid arthritis

Severely Obese (40+)

Stable Angina

STEMI

Stroke/TIA

Undergone a percutaneous coronary intervention (PCI)

Other

Medication & Dosage

By completing this form, you agree to BPL processing and storing your personal data for the purpose of your participation in the BPL Health referral program, 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 BPL 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. Find more about BPL Privacy Policy at bpl.org.uk/privacy

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