Cotswold Exercise Referral Form

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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Cotswold Gym Exercise Self-Referral Form

Your Details

Baseline Measures

Clinical Diagnosis and/or current problems

Medication Prescribed

Chair Stand Test

Hay Fever