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Referred by

Name of Referral

Email Address

Address

Phone Number

Reason for Referral

CHD Risk Factors

Mild Anxiety/Depression

High BMI/Overweight

High Blood Pressure

Arthritis

Other

Please give further detail on the above

Sessions of Interest

Preferred means of contact

Phone

Either

Has Your Doctor Ever Said you have a heart condition or high blood pressure?

Yes

Do you feel pain in your chest at rest, during daily activity or when doing physical activity?

Yes

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

Have you ever been diagnosed with a chronic medical condition?

Yes

Are you currently taking prescribed medication for a chronic condition?

Yes

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?

Yes

Has your doctor ever said that you should only do medically supervised activity?

Yes

Language Preference for Call Back

English

Welsh

I confirm I have consent to make this referral

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If answered yes to any of the above, please provide more details.

Partners

Badmington Wales
Basketball Wales

Enw

Rhif Aelodaeth (os yw’n hysbysu/berthnasol)

Rhif Cyswllt

Cyfeiriad E-bost

Dull cysylltu dewisol

Amser cysylltu dewisol

Lleoliad

Rhydaman

Caerfyrddin

Llanelli

Llanymddyfri

Castell Newydd Emlyn

Sancler

Hendy gwyn a’r daf

Cydweli

Pencader

Llansawel

Talacharn

Llanybydder

Porth Tywyn

Hendy

Trelerch

Pontiets

Diddordeb mewn

Beth yw eich ymholiad?

Drwy lenwi’r ffurflen hon rydych yn cytuno bodgennych ganiatad i bod gennych ganiatâd i rannu’r wybodaeth uchod ac nid yw’r person sy’n cael ei gyfeirio o dan unrhyw ymchwiliad meddygol ar hyn o bryd.

Yes, I give permission to store and process my data

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Partners

Badmington Wales

Basketball Wales