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Kirklees Active Leisure - Online Referral Form

Fitness for Work

This programme aims to help people to get back to health and back to work, by combining lifestyle change support with structured exercise.

Inclusion Criteria

Before completing your referral, please confirm that you meet the following criteria:

Referral must be aged 18 or over to be eligible .
Committed to making a long term lifestyle change .
Referral must be clinically stable and compliant with their medication .
Referral must also meet one of the following criteria:
- Currently out of work due to ill health.
- Had sickness from work due to ill health for more than 7 days in the last 6 months.
- At risk of falling out of work due to ill health.

Exclusion Criteria

The following conditions are excluded from the exercise referral scheme:

Resting tachycardia > 100bpm.
Systolic blood pressure (BP) > 180mmHg and/or Diastolic BP > 100mmHg.
New or uncontrolled arrhythmias.
Unstable diabetes.
Unstable angina.
Unstable mental health status.
Unstable or acute heart failure.
Symptomatic hypotension.
Febrile Illness.
Any other condition which may be exacerbated by exercise.

Fields marked with an * are required fields.

At least one of the following must be ticked to be eligible for this programme. *
Currently out of work due to ill health. Had sickness from work due to ill health for more than 7 days in the last 6 months. At risk of falling out of work due to ill health.

Your personal details

Title

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

Biological Sex *
Male Female Intersex Unknown

Health Questionnaire

Do you have any of the following heart or lung health conditions? *

YesNo

Coronary Artery Disease (CAD)
Heart Failure
Irregular Heart Beat
Valve Disease
Heart Attack (Myocardial Infarction)
Congenital Heart Disease
Pericarditis
Myocarditis
Cardiac Tamponade
Sudden Cardiac Arrest
Aortic Disease
Peripheral Artery Disease (PAD)
Stroke
Transient Ischemic Attack (TIA)
Aneurysm
Embolism and Thrombosis
Deep Vein Thrombosis (DVT)

Pulmonary Embolism
Hypertension (High Blood Pressure)
Rheumatic Heart Disease
Vasculitis
Vascular Dementia
Angina
Palpitations
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Cystic Fibrosis
Lung Cancer
Pulmonary Fibrosis
Pulmonary Embolism
Pulmonary Hypertension
Mesothelioma
Interstitial Lung Diseases
Lymphangioleiomyomatosis (LAM)

Do you suffer with any of the following: *

High blood pressure

High cholesterol

Kidney disease

Diabetes

Not applicable

Do you suffer from any of the below symptoms: *

Chest pain

Shortness of breath

Puffing/wheezing

Swelling of legs ankles or feet

Numbness of extremities at rest

Heart palpitations

Not applicable

Do you suffer with significant back pain? *
YesNo

Do you have an unstable mental health condition? *
YesNo

Do you have any other conditions that may impact your ability to exercise safely OR have any reason to believe that taking part in physical activity may be inappropriate for you? *
YesNo

First Language

NHS Number

Religion

Sexual Orientation

Emergency Contact Name

Emergency Contact Number

Relationship To Patient

Emergency Contact Email Address

Height (cm)

Weight (kg)

Blood Pressure (mm/Hg)

Heart Rate (bpm)

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

Any existing medical conditions? * YesNo

Medication (tick all that apply)

Alendronate

Amlodipine

Aspirin

Atorvastatin

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

Reason for referral *

How did you hear about this service?

Preferred leisure centre to attend

Consent

I agree that KAL can process my personal details, including medical information, for the purposes of accessing KAL’s Health & Wellbeing programmes in line with the information supplied in the Privacy Notice. For full details how we use your information please see our Privacy Notice at privacy.kal.org.uk

I agree that KAL can share my personal details with the University of Huddersfield, NHS West Yorkshire Integrated Care Board (ICB) and Locala for the purposes of statistical research.

I agree that KAL can share my personal details and attendance data with the DWP for the purpose of engagement monitoring.

I have read and agree to the Health Commitment Statement, Exercise Referral Terms and Conditions and understand the KAL's Centre Terms of Use apply

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