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Tilehurst Surgery The Potteries

Pathway exercise referral

Pathway Exercise Self Referral Form

Section

Home Address

Please include postcode

Name of your GP

Name of GP Practice

Reasons for referral (Aims and objectives):

Is there any history of any of the following conditions?

Hypertension

Coronary Heart Disease

Asthma

Diabetes

Other

Please give details

Resting Heart Rate

BMI:

Additional Comments (including any exercise restrictions)

Readiness to change (become more active)

1 – Not ready to change

2

3

4

5

6

7

8

9

10 – Ready to change

*

I agree for the above information to be given to the Pathway Fitness Consultant

Date

If you are human, leave this field blank.

Tylers Place
Pottery Road
Tilehurst
Reading
RG30 6BW

Get directions

0118 942 7528

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

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