Cotswold exercise referral

Your Details

Your Name

Preferred Phone Number

Home Address

Please include postcode

Baseline Measures

Resting Heart Rate

Heart Rate Regular

BP Systolic “Higher”

BP Diastolic “Lower”

Clinical Diagnosis and/or current problems

1

2

3

4

Medication Prescribed

1

2

3

4

5

6

Possible effects of current medication and/or patient diagnosis on patient’s safe/comfortable conduct of exercise

Prohibited Activity – If there are any activities that your doctor DOES NOT wish you to take part in please indicate

Susceptible to:

State of Health behaviour change (indicate activity status)

Chair Stand Test

Four Test Balance Scale (please tick if accomplished)

Feet together – 10 sec

Tandem Stand – 10 sec

Semi-Tandem – 10 sec

One leg stand – 10 sec

Falls (please tick appropriate response)

History of falls

Use of walking aid

Anxious of falling

Unconfident out of class

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 new or unusual symptoms. I will also inform the instructor of any changes in my medication, the results of any investigations or treatment.

Signature:

Date

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Your Details

Baseline Measures

Clinical Diagnosis and/or current problems

Medication Prescribed

Chair Stand Test