Physical Activity Referral Form
Client Details (referrer to complete this section)
Name
Contact Number
Mr
/
Mrs
/
Ms
/
Title
D.O.B
Gender
Male / Female
Dr
Address
Postcode
GP Name
NHS Number
GP Surgery
Referrer Details (referrer to complete this section)
Name
Job Title
Location
Contact Number
Signature
Date
Primary Reason for Referral
Cancer
Prostate
Breast
Colorectal
diagnosis
Other (please state)
Medical History (client to complete remaining sections)
Other Medical
Medication
Condition (s)
(s)
Please attach a
printout where
possible
Limitations
Any side effects experienced?
(please circle all that apply)
Previous
cancer
treatments
Future cancer
treatments
planned?
Osteoperosis
Cardiotoxicity
Fatigue
Lymphoedema
Limited range of
movement
Yes / No
Referrer must complete the first two sections and send to the address below.
Preferred Activity Choices (please circle all that apply)
Walking
Gym based
Cycling
Class based
Water based
Sport
Patient Consent
The exercise referral programme has been fully explained to me. I am prepared to participate and I
give permission for this information to be passed onto the physical activity service.
Signature
Date
Emma Trent ~ Health Manager
Portland Centre, Muskham Street, Meadows, Nottingham, NG2 2HB
Client to complete
Programme Venue and Time
Start Date
Email Address
Age
Wk1 6min test:
Wk1 Step test:
Height (m) - OPTIONAL
m Wk6 6min test:
bpm Wk6 Step test:
m
bpm
Ethnicity (please tick)
White: British
White: Irish
White: Other White
Mixed: White and Black Caribbean
Mixed: White and Black African
Mixed: White and Asian
Mixed: Other Mixed
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Weight (kg) - OPTIONAL
BMI - OPTIONAL
Wk12 6min test:
Wk12 Step test:
Improvement:
Improvement:
m
bpm
m
bpm
Asian or Asian British: Bangladeshi
Asian or Asian British: Other Asian
Black or Black British: Caribbean
Black or Black British: African
Black or Black British: Other Black
Chinese or other ethnic group: Chinese
Other ethnic group: Other Ethnic Group
Not specified
Emergency Contact Details
Name
Relationship
Address (if different from above)
Contact Number(s)
Self-Referral
I confirm that I am no longer receiving hospital based treatment and that I feel I am able to take part in a physical
activity programme. I realise that my body’s reaction to exercise is not totally predictable. Should there be
something that affects my ability to exercise, I will inform the instructor running the programme immediately and
stop exercising if necessary. I take full responsibility for monitoring my own physical condition at all times.
Data Protection
We keep your records confidentially and securely. From time to time, our partners ask for information for
monitoring & evaluation purposes to help us improve our service ~ please tick this box if you would not like us to
share your information
Filming and Photo Consent
I understand that from time to time, Notts County FC, Football in the Community may organise for photographs or
filming to be taken during the session. All such official photographs & filming will only take place by an approved
person organised by Notts County FC, Football in the Community, & used to promote the Motivate programme.
~ please tick this box if you would not like us to share your information
Print:
Signed:
Date: