REFERRAL FORM
Community Exercise Scheme for Chronic Respiratory Disease
Patient Name
Assessed by
Ethnicity (Refer to key on page 2 for code)
Patient Address
Male/Female
Age
Postcode:
Telephone Number
Marital Status
Assessment Date
Divorced
Married
Single
Widowed
Partner
Separated
Consultant Name
GP Name
Main Diagnosis
Arthritis
CFA
Heart Failure
Respiratory Failure
Asthma
COPD
Hyperventilation
Lung Cancer
Bronchiectasis
Emphysema
Ischaemic Heart Disease
Other
Concurrent Diagnosis
Abdominal Aneurysm
Angina
Aortic Valve Disease
Atrial fibrillation
Cancer
CVA
Heart Failure
Ischaemic Heart Disease
MRSA Positive
Osteoporosis
Allergic Broch. Asp.
Ankylosing Spondylitis
Aortic Valve Replacement
Bronchiectasis
CFA
Depression
Hypertension
Lung Cancer
Myocardial Infarction
Rheumatoid Arthritis
Alpha 1Antitrypsin Deficiency
Aortic Stenosis
Asthma
CABG
COPD
Diabetes
Intermittent Claudication
Mitral Valve Replacement
Osteoarthritis
Peripheral Vascular Disease
Other
Height (m)
Weight (kg)
Home Cylinder
Yes
No
Smoking History
Yes
No
Ex
Attended Pulmonary
Rehabilitation
Yes
No
If Yes, date of completion
Medication
Pack Years
Visit
Date
BORG (rest)
FEV1 (within last year, if known)
FVC (within last year, if known)
Sa02
Heart Rate (resting)
In your opinion, can you identify
any reason for this person not to
participate
If Yes to above, please comment
Class Content
Patients Goals:
L
L
Current Activity Levels:
Yes/No
KEY:
IMPORTANT NOTICE
Ethnicity codes

White
British
1
Irish
2
Any other white background
3
Mixed



The patient exhibits no contraindications to exercise
(as indicated on the protocol)
The patient is clinically stable
The client is compliant with medication
The patient is awaiting / not awaiting further medical
or surgical treatment (see protocol)
REFERRER’S SIGNATURE:_________________________
White and Black Caribbean
4
White and Black African
5
Print Name___________________ Date:_______________
White and Asian
6
GP’s signature (if different from above): ________________
Any other mixed background
7
Asian or Asian British
Indian
8
Pakistani
9
Bangladeshi
10
Any other Asian background
11
Black or Black British
Caribbean
12
African
13
Any other Black background
14
Other ethnic groups
Chinese
15
Any other ethnic group
16
Not stated
17
Print Name:___________________ Date:_______________
PATIENT INFORMED CONSENT
I agree for the above information to be passed onto the
exercise instructor. I understand that I am responsible for
monitoring my own responses during exercise and will inform
the instructor of any changes in my medication, the results of
any investigations or treatment.
PATIENT SIGNATURE: __________________________
Print Name:____________________________________
Date: _________________________________________
Patient - please hold onto this form and contact the following person
to chat about your referral and arrange attending their session :
Jeremy Bingham Respiratory Rehab Instructor who
delivers these sessions on 07748539308 or email to
him at fitbing@hotmail.co.uk
Patient Criteria
Referral Pathways for the transition of Chronic Respiratory Disease Patients to
Community Based Exercise Provision
The approved referral pathways for an individual with chronic respiratory disease
wishing to access community based exercise provision are described below
COPD Patient
confirmed diagnosis
of COPD
Completed pulmonary
rehabilitation
Mild patients MRC
Grade 1-4
(FEV1 > 50%)
Referred by
rehabilitation team
Assessed and
referred by health
care professional
Community based
exercise session
Community based
exercise session
This pathway is to be used for mild COPD patients (MRC Grade 1,2 , 3 or 4* and
FEV1 predicted > 50%) who have recently been diagnosed and/or do not currently
require pulmonary rehabilitation
These patients would need to be referred from their GP to a HCP who would assess
the patients following the above procedure and complete the recommended referral
form.
The patients consent should be obtained and the referral form completed by both the
HCP and the individual being referred. The transfer form should be given (either) to
the individual being referred as a hand held document or (where protocol permits)
forwarded directly to the exercise professional.
If the exercise professional is satisfied that the patient should be transferred to the
scheme and there have been no new events or symptoms in the interim, the patient
can be accepted for the exercise programme.
*MRC dyspnoea scale
MRC Grade 1: Not troubled by breathlessness except on strenuous exercise.
MRC Grade 2: Short of breath when hurrying or walking up a slight hill
MRC Grade 3: Walks slower than contemporaries on level ground because of
breathlessness, or has to stop for breath when walking at own pace
MRC Grade 4: Stops for breath after walking about 100m or after a few minutes on
level ground
M
Absolute Contraindications of Exercise









Unstable angina
Unstable or acute heart failure
Unstable diabetes
New or uncontrolled controlled arrhythmias
Resting or uncontrolled tachycardia >100bpm
Symptomatic hypotension
Resting SBP> 180mmHg or resting DBP > 100mmHg
Symptomatic hypotension
Febrile illness