Search ...

Login to your account

Remember Me

Log in

• Forgot Login?
• Sign up

Health Lifestyle Action - Self Referral Form

Please complete all required fields!

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)(*)

Invalid Input

Address (*)

Invalid Input

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

Invalid Input - Numbers only

Email Address(*)

Invalid Input

Date of Birth(*)

Day01020304050607080910111213141516171819202122232425262728293031 / Month010203040506070809101112 / Year1960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020 Invalid Input

NHS Number (if known)

Invalid Input

What is your First Language?(*)

Invalid Input

Do you require an interpreter?(*)

YesNo

Invalid Input

To which gender do you most identify?

Female

Male

Transgender Female

Transgender Male

Gender Variant/ Non- Conforming

Not Listed - please specify below

Prefer Not to Answer

Invalid Input

If Not Listed - please specify

Invalid Input

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

White

British

Irish

Any other White background

Mixed

White and Black Caribbean

White and Black African

White and Asian

Any other mixed background

Asian or Asian British

Indian

Pakistani

Bangladeshi

Any other Asian background

Black or Black British

Caribbean

African

Any other Black background

Other Ethnic Groups

Chinese

Any other ethnic group – please specify below

Not stated – please specify below

Invalid Input

Please Specify

Invalid Input

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

Invalid Input

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

Invalid Input

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

Invalid Input

What is your Usual GP's Full Name?

Invalid Input

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

Invalid Input

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

North - Eastcote Health Centre

Central - Civic Centre, Uxbridge

South - The High Street Practice, Yiewsley Health Centre

Virtual

Invalid Input

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

Type 1 Diabetes Melitus

Type 2 Diabetes Melitus

Asthma

Hypertension

COPD/Emphysema

Hypercholesterolaemia

Cardiovascular Disease

Other- please state below

None

Invalid Input

If other please specify

Invalid Input

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

Invalid Input

GDPR(*)

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

Invalid Input

Anti Spam(*)

Invalid Input

Submit Form

Submit Clear form

© The Confederation Hillingdon. Developed by 3cellhosting.