Cotswold exercise referral

Section

Your Details

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: