Referral to Physical Activity Team
Name:
D.O.B:
Address:
NHS number:
Telephone number:
GP:
GP address:
Referrer details (name, position, address), if not GP:
If not the GP, please tick to confirm you have gained the GP’s agreement to
refer 
Essential Criteria
Registered with a Furness Practice
Aged 16 years or over
Clinically stable
Reason for Referral
Anxiety/ Depression

Asthma/COPD

Cancer
Chronic Heart Disease
Diabetes
Hypertension







Musculoskeletal condition (specify) 
………………………………….
Neurological condition -CVA

- MS

- Parkinson 
Obesity/weight loss

Osteoarthritis

Other (please specify)

……………………………………
Specific Outcome to be achieved:
Current and past health problems
Medication
Possible effects of current medication and/ or diagnoses on patient
when undertaking physical activity:







Heart rate not an indicator of exercise intensity
Suppression of pain
Angina
Hypotension
Hypoglycaemia
Dizziness
Other (please state)
Lifestyle factors
 Smoker
 Alcohol
Packs per week…………
Units per week…………
Current level of physical activity: How often does the patient do 30
minutes of moderate exercise per day?
Never
a week
Less than once a week
1-4 times per week 5+ times
Gym activities you DO NOT wish the patient to take part in:
Baseline measures
BP:
HR:
Weight:
BMI:
Lone worker screening
History of violence and/ or aggression
History of drug abuse
History of alcohol abuse
Any special needs required?
Yes
Yes
Yes
Yes
or
or
or
or
No
No
No
No
If you have answered YES to any of the above questions, please give details
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
I have explained the risks and benefits of exercise to the patient, and I will
inform the gym if there is a change in the patient’s condition. I accept that
responsibility for the administration and delivery of the exercise programme
lies with the gym staff but clinical responsibility for the patient remains with
me.
Signed:
Date:
General Practice Physical Activity Questionnaire completed and attached

Please return completed forms to: Physical Activity Team, c/o Hoops
Basketball Centre, Thorncliffe Road, Barrow in Furness, Cumbria, LA14 5QA
Please note incomplete forms will be returned and are likely to
cause a delay in referral.