PALS referral form_23.1.09:3450 KMCGraphics referral form
23/1/09
11:40
Page 1
Referral Form Patient Detail
Mr/Mrs/Ms/Miss
Name: Address: Postcode: D.O.B.
Tel No:
Declarations I have been fully informed about PALS and have not withheld any relevant information. I will advise my referring agent of any further changes to my health. Patient’s Signature
Patient’s G.P.:
Essential Criteria 16 years plus Inactive Motivated/Compliant
A B
Referring Agent I have fully briefed this patient and I now refer this person to PALS Name (PRINT) Signature Profession (PRINT)
Surgery/Department (PRINT)
All boxes must be completed Yes
Selected Criteria
Date:
Patient’s Surgery:
C
D E F G H I J
Yes Resident in Kirklees and/or a Patient registered with one of the General Practices responsible to the Kirklees PCT.
Please tick one or more
Yes
Low self esteem, mild anxiety or depression At risk of/have CHD (must have two or more risk factors) Please indicate I) II) Hypertension Blood Pressure Must not exceed 190/100 Resting HR Asthma and other respiratory problems Joint pain, back pain, arthritis, osteoporosis or similar At risk of/have diabetes Stroke B.M.I. >25 Please state Fallen/at risk of falling Chronic/Persistant pain
Re-Referral
Yes
No
Yes
No
Has this patient had a previous referral? If yes, why has this person been re-referred?
Date
Once signed by both parties the PATIENT should wait approximately 5 days then contact the PALS office to make an appointment. Call between 9.00am and 4.00pm on 01484 234095. The form is only valid 3 months from the date above. All sections must be complete or the form is invalid.
Medication
Is this patient taking any medication? If yes, please tell us how this may affect the patient’s ability to undertake physical activity/exercise.
Health and Medical Factors It is important that the instructor is aware of any past/current health and medical factors which may affect the patient’s ability to undertake physical activity/exercise. Please give details if appropriate and attach relevant information if necessary.
Prohibited Activities Please list any types of activity this patient should NOT take part in.
PALS, Kirklees Culture & Leisure Services, The Stadium Business & Leisure Complex, Stadium Way, Huddersfield HD1 6PG Contact No.: 01484 234095 1. WHITE COPY TO PALS OFFICE 2. BLUE COPY TO PATIENT 3. YELLOW COPY FOR REFERRAL AGENT