Self Referral Form

Thank you for your request to join the Health, Lifestyle, Action Programme.

Please ensure all required fields are completed before submitting the form.

Full Name (forename and surname)(*)

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Address (*)

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Phone Number (the best number for our team to contact you on)(*)

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Email Address(*)

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Date of Birth(*)

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NHS Number (if known)

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What is your First Language?(*)

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Do you require an interpreter?(*)

YesNo

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Which Gender do you most identify with?(*)

If Not Listed - please specify

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How would you best describe your ethnic background? (*)

Please Specify

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What is your Religion?

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What is your current employment status?(*)

What is your Sexual Orientation?(*)

If other please specify

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Are you Pregnant?(*)

YesNoN/A

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Do you have any known Disabilities?(*)

Yes (please specify below)No

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If Yes, please specify

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Do you have a diagnosed Mental Health condition?(*)

Yes (please specify below)No

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If Yes, please specify

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What is your current Body Mass Index? (If known)

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What is your current height? Please submit in centimeters(*)

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What is your current weight? Please submit in kilograms(*)

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Please state the name of your Hillingdon GP Practice(*)

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Please select preferred location (select up to 4)(*)

North - Eastcote Health Centre

Central - Civic Centre Uxbridge

South - The High Street Practice

Online Via Zoom

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Significant Medical History. Please select if you have a medical history of any of the following:(*)

If other please specify

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Patient Declaration(*)

I confirm that I am 16 years old or over, with the ability to exercise and do not use mobility aids.

I am willing to commit to the full 12 week programme

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GDPR(*)

I hereby give consent for my Health Lifestyle Action record to be shared with my registered GP Practice.

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IMPORTANT NOTICE: The information collected in this questionnaire is strictly confidential, and for use by Programme staff only. Together with information collected at each of the sessions, it will be used to guide your treatment. In some cases, anonymised data may also be submitted to our public health partners for research purposes. Please discuss any concerns you may have regarding this information with the clinic staff at any time. If you do not wish for your data to be used in this way, then please let the team know at the time of booking and we can discharge you from the programme.

Anti Spam(*)

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Health Lifestyle Action - Self Referral Form

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Health Lifestyle Action - Self Referral Form