Cotswold Exercise Referral Form

To self-refer to the Cotswold gym exercise service please complete this form.

Cotswold Gym Exercise Self-Referral Form

Cotswold Gym Exercise Self-Referral Form

Your Details

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please include postcode

Baseline Measures

Clinical Diagnosis and/or current problems

Medication Prescribed

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

please note the number of seconds
Four Test Balance Scale (please tick if accomplished)
Falls (please tick appropriate response)