Leeds Encouraging Activity In People (LEAP)

Leeds Encouraging Activity in People

Exercise Referral Scheme for people with long term health conditions.

Inclusion Criteria

Essential Criteria - Participant must meet ALL of these criteria:
- Is aged 18 years or over.
- Is motivated for exercise.
- Currently Inactive or low active.
- Has given consent to be referred to the LEAP scheme.
- Has no contraindications for exercise.
- Is considered by the health professional to be clinically fit for safe participation in community-based exercise.
- Does not require specialist treatment e.g. physiotherapy.
- To be able to receive instructions independently. .
Medical Criteria - Participant must also have AT LEAST ONE of these criteria:
- Has a long-term medical or mental health condition AND is likely to benefit clinically from regular exercise participation.
- And /Or has multiple risk factors for developing CVD.
- And /Or has a BMI > 30.

Exclusion Criteria

Participant should not take part with one of the following:
- Contraindications to exercise.
- Cardiomyopathy.
- Suspected or known aneurysm.
- Resting systolic BP > 180mmHg or diastolic BP > 100mmHg.
- Uncontrolled resting tachycardia ≥ 100bpm.
- Uncontrolled diabetes.
- Uncontrolled/unstable angina.
- Unstable or acute heart failure.
- New or uncontrolled arrhythmias.
- Severe breathlessness or dizziness.
- Febrile illness/acute systemic illness.
- Dementia, Alzheimer’s or severe cognitive impairment (unable to follow simple instructions).
- Anyone who is currently an Active Leeds member or has been an Active Leeds member within the last 3 months.

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 *

Marital Status *

Sexual Orientation *

First Language *

Employment Status *

NHS Number

Reason for referral *

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)

Atrial / Ventricular fibrillation

Back Pain

Cancer

CHD

Chronic Fatigue/ME

COPD

COVID Recovery

CVD event post 6 months

CVD event within last 6 months

Dementia

Depression

Depression (clinical)

Diabetes (Type 1)

Diabetes (Type 2 Insulin treated)

Diabetes (Type 2)

Epilepsy

Hearing Impairment

Hypertension

Hypertension (controlled)

Impaired mobility

Is pre diabetic (HbA1c 42-47 mmol/mol)

Learning disability

Mental health condition

Mobility Problems

Musculoskeletal (pain/injury)

Neurological

Obese (30-39.9)

Overweight (25-29.9)

Post Surgery

Pregnancy

Respiratory disease

Severely Obese (40+)

Stroke/TIA

Other

Are you on any medication (Please bring your current prescription to your first appointment) * YesNo

How did you hear about this service? *

Your preferred centre to attend

Consent

I understand that I am completing a referral request. By completing this form, I consent to ReferAll processing and storing my personal data for the purpose of my referral into a ReferAll programme. I understand the information provided is essential to my referral and consent to this information being stored securely in accordance with the General Data Protection Regulations (GDPR – 2018). Personal data will only be used by ReferAll 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. For further details about how Active Leeds will store and use your personal details, please see our privacy statement: Active Leeds TCs - Privacy Statement

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