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Everyone Active - Winchester Online Referral Form

Winchester Sports Park – Health & Wellbeing Programme

The health and wellbeing programme for long term health conditions is a 24 week programme for clients who have a chronic disease or who are at risk of developing chronic disease.

The following long term health conditions will need a referral from a Health Professional: Stroke, Parkinsons, Cancer, MS or Cardiac.

Exclusion criteria: Systolic Blood Pressure = 180mmHg and/or diastolic = 100mmHg – if you are unsure of your blood pressure please contact a Health Professional prior to self-referral. Please note we may require further information or confirmation from a health professional to certify you are safe to take part in the programme.

Inclusion Criteria

Sedentary.
Aged 16 years or over (no upper age limit).
You have been diagnosed with long term health condition which could benefit from regular physical activity.

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 *

Height (cm) *

Weight (kg)*

First Language *

Nationality *

Employment Status

GP Practices

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

Mental Health Condition (Other)

Motor Neuron Disease (stable)

Multiple Sclerosis (stable)

Musculoskeletal (pain/injury)

Neurological

Obese (30-39.9)

Osteoporosis

Overweight (25-29.9)

Parkinson's Disease (stable)

Pre-diabetic

PVD

Recent Surgery

Rheumatoid arthritis

Severely Obese (40+)

Stress/Anxiety

Stroke/TIA

Other

Medication (tick all that apply)

Alendronate

Amlodipine

Aspirin

Beclomethasone

Bendroflumethiazide

Bisoprolol

Chondroitin

Citalopram

Digoxin

Fluoxetine

Furosemide

Gabapentin

Gliclazide

Glucosamine

GTN Spray

Insulin

Isosorbide Mononitrate

Lansoprazole

Lyrica

Metformin

Methotrexate

Metoprolol

Mirtazapine

Orlistat

Perindopril

Pravastatin

Prednisolone

Ramipril

Rivaroxaban

Salbutamol

Simvastatin

Spironolactone

Tramadol

Ventolin

Warfarin

Other Medication

Reason for Referral *
Please describe why you would like to take part in the health & wellbeing programme

Consent

I agree to the release of medical details about me to the service provider. I understand my details will be stored on a secure database system in an appropriate confidential manner. I agree to be contacted by letter, email, telephone and SMS text message. Everyone Active privacy policy can be found here - www.everyoneactive.com/legal-policies/privacy

Everyone Active will manage this data securely and in accordance with all relevant Data Protection laws. We will use this data for managing the services we provide. Full details of how we manage this data can be found in our privacy policy at EveryoneActive Privacy Policy. If you are happy for us to process this data please tick here.

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