Working for us
Health and Wellbeing professional
Name of Referral
Reason for Referral
CHD Risk Factors
High Blood Pressure
Please give further detail on the above
Sessions of Interest
Preferred means of contact
Has Your Doctor Ever Said you have a heart condition or high blood pressure?
Do you feel pain in your chest at rest, during daily activity or when doing physical activity?
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?
Have you ever been diagnosed with a chronic medical condition?
Are you currently taking prescribed medication for a chronic condition?
Do you currently have (or in the past 12 months) have a bone, joint, soft tissue injury that may be made worse by physical activity?
Has your doctor ever said that you should only do medically supervised activity?
Language Preference for Call Back
I confirm I have consent to make this referral
If answered yes to any of the above, please provide more details.