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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 the referral, please confirm that they meet the following criteria:

Referral must be aged 18 or over to be eligible for this service.
Committed to making a long term lifestyle change.
Clients 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.

Referrer Details

First name

Surname

Phone number

Email address *

Profession

Referring organisation

Please indicate whether you are a registered primary care or allied health professional. *

I confirm I am a registered primary care or allied health professional and consider the exercise referral programme to be an appropriate part of the patient's treatment plan.

I am not the registered primary care or allied health professional.

All referrals must have clearance from a GP or health professional. If you are not the registered GP or health professional, by completing the information you are confirming the below named GP or health professional (qualified medical practitioner) has approved this referral and considers the exercise referral programme to be an appropriate part of the patient’s treatment plan.

First name *

Surname *

Phone number *

Email address *

Profession *

Referring organisation *

Details of the person being referred

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 *

Biological Sex *
Male Female Intersex Unknown

Gender *

Date of birth *

First Language

Ethnicity

NHS Number

Religion

Sexual Orientation

Emergency Contact Name

Emergency Contact Number

Relationship To Patient

Emergency Contact Email Address

Reason for referral *

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

How did the patient hear about this service?

Consent

To the best of my knowledge, the information provided is an accurate representation of the above patient’s health. I believe the named patient to be clinically stable and medically safe to participate in a structured exercise referral programme.

I have informed the patient about KAL’s exercise referral schemes, and the patient has consented to all their information on this form being passed to KAL to contact them.

Some of the form fields are required. Please check you have filled out all required fields.

Tick if you want to download a copy of the form as a PDF file.

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