FREE 12
WEEK
WEIGHT
MANAGEMENT PROGRAMME
This course
aims to support adults to reduce weight through healthy eating and increased
exercise.
On
completion of the course you will also receive 3 FREE additional quarterly
support sessions.
|
This course will equip you with the knowledge
and confidence to reach and sustain a healthy weight for life and is
delivered to a high standard, by Infinite Joy qualified trainers, following best practice, complying with
the National Institute of Clinical Excellence (NICE) guidelines. If you wish you can copy the Referral
Form in the box below and return it to us by post or fax you can complete it
yourself (self refer) or if you have any of the conditions on the list get
your GP to advise and sign. Send it
to: Infinite Joy NN7 9BG Fax Number: 01604 289727 On receipt of the form you will be
contacted and enrolled on a course. If you have any questions please call mobile
07884126378 |
||||||||
|
Infinite Joy Weight Management on
Referral Form Service
User Information Name
............................................
Sex: Male O
Female O Address
.........
..
.
.Date of Birth: ..
... /
..... /
...
.
..
.
..Tel
No:
.
.
.. Post
Code
..
..
.. Registered GP:
.
. Ethnicity
Categories
.
...
Disability
.
.
. Smoker O yes O no Pregnant O yes O no Baseline Measures BMI
...
kg/m² Current Weight
.
kg OR
..
lbs O measured O reported Current
Height
..cm OR
..
in O
measured O reported Medical
History Where a medical condition or
co-morbidity is present then the referral needs to be made through a GP,
practice nurse, or clinical staff working in secondary care who have access
to the patients medical records and are appropriately qualified to make a
judgement on whether the patient is suitable to take part in a healthy eating
and physical activity programme. Moderate
Cholesterol O Stress/Depression O Diabetes
Type I or Type II O Asthma O Cystic
Fibrosis O Hypertension O Neurological
Conditions O Fybromialgia O Stable
Angina O Surgical
Preparation & Recovery O Chronic
Obstruction Airways Disease/Pulmonary O Intermittent
Claudication O Valvular
Heart Disease O Arrhythmias O Coronary
Surgery Rehabilitation O Back
Surgery O Complex
surgery O Patients
who are in the process of treatment for cancer (must be in remission) O Hypertensives
Medicated or with BP>160/100 O Current
Medication
.
.. Addition
Information
.
Referrers Information I refer this service user to the
weight management on referral scheme under the agreed terms and conditions. GP/Health Care
Professional Name:
. GP/Health Care
Professional Job Title:
...
.
. GP/ Health Care
Professional Signature: .
... Medical
Practice
.
.
. Telephone Number
.. Please
confirm that the service user is motivated and has agreed to this
referral O Date
of referral:
/
./
. Patient
Informed Consent This scheme has been fully
explained to me. I wish to decrease my current weight by participating in the
scheme. I give my consent for any relevant clinical information about my
health and participation on this scheme to be used for evaluation and
monitoring purposes. I consent to my information being stored on a database
for audit purposes (in accordance with the Data Protection Act 1977) Patients
Signature:
.
.
.
Date:
./
./
|
|||||||||
|
|
Obesity is associated with increased
risk of a range of chronic illnesses including type 2 diabetes, coronary heart
disease, hypertension (high blood pressure), gall bladder disease, stroke and
some cancers. Ask your GP or health professional for a referral, or
self refer by contacting: Infinite Joy Email: admin@infinitejoy.org.uk Fax: 01604
289727 Phone: 07884126378 |
||||||||