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Healthwise
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HEALTHWISEPHYSICAL ACTIVITY REFERRAL SCHEME
Working in partnership with
REFERRERS MANUAL
HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME3
CONTENTSWELCOMEWelcome Message 04
GENERAL INFORMATIONWhat is Healthwise? 06Who’s running it and where? Who should you refer?What activities are available? How do you refer someone?What’s the cost?
HOW TO MAKE A REFERRALThe Referral Pathway 10
HOW TO MAKE A CARDIAC REFERRALCHD Patient Referral Pathway 12Cardiac Referral Forms Route 1 & 2
INCLUSION/EXCLUSION CRITERIA Inclusion Criteria 16Exclusion Criteria Contraindications
CONTACT USContact Details 24
APPENDICIES How to make a referral 28 Healthwise Referral Form Healthwise Cardiac Referral Form Notes
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GENERAL INFORMATION
WELCOMEMessage from Steve Ward, GLL Chair
GLL in partnership with NHS Greenwich and the London Borough of Greenwich are working to encourage residents to get active through an innovative Physical Activity Referral Scheme.
The Scheme provides local residents with a high quality service and affordable leisure facilities within the Greenwich Leisure Centres. The Healthwise Scheme has a special focus on people with medical conditions or other specialist needs that might discourage or prevent them from exercising, helping them to fi nd a suitable way to get fi t and stay healthy. After referral from a doctor or other health professional a dedicated team of Exercise Professionals will assess the patient to take account of current fi tness levels and any special requirements they may have. A suitable, safe and personalised exercise programme will then be designed. The Healthwise team are on hand within the Leisure Centres to offer advice on exercise, diet and healthy lifestyles. Progress is monitored and the exercise programme can be adjusted accordingly.
We are sure that you will fi nd that the Leisure Centres offer great facilities for all and we are certain that we can help individuals get fi tter and healthier in an enjoyable way!
For more information on the Physical Activity Referral Scheme, please contact the Healthwise team on 020 8317 5000 ext. 2130.
Yours sincerely
Steve Ward – GLL Chair
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HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME7
WHAT IS HEALTHWISE?Healthwise is an Physical Activity Referral Scheme (PARS), where Health Professionals can refer patients to a low cost physical activity programme. It is designed for individuals with existing health conditions, such as CHD and Asthma, as well as those at risk of developing health conditions, such as diabetes, obesity and depression.
WHO’S RUNNING IT AND WHERE?GLL are offering this service at the following Leisure Centres in Greenwich:
• Arches Leisure Centre • Coldharbour Leisure Centre
• Eltham Centre • Thamesmere Leisure Centre
• Waterfront Leisure Centre
The Healthwise team are a highly qualifi ed team based in the Leisure Centres dedicated to the provision of safe and effective exercise. All facilitators are Level 3 exercise referral qualifi ed as a minimum.
WHO SHOULD YOU REFER? (OVER 16’S ONLY)
Healthwise is designed for Greenwich residents who are currently not active, but would benefi t from physical activity. We recommend that you explore thoroughly with each patient whether they are ready to start an exercise programme. An individuals readiness to change refers to the patient’s state of mind regarding exercise. If an individual is ready to become more active evidence suggests that this helps to facilitate physical activity in the long term.
We ask that you read the inclusion criteria carefully before referring a patient and refer only patients with whom you have discussed the Healthwise Scheme and who you feel are ready to participate in a physical activity programme. The scheme is not a long term solution for those requiring one to one attention but one that helps individuals increase knowledge and confi dence in their journey to becoming more active.
WHAT ACTIVITIES ARE AVAILABLE? All patients will receive an individually tailored exercise programme dependent on their needs. In addition to this, group based activities will be available. Exercise options include, but are not limited to:
• Gym Based Supervised Sessions• Waterbased Exercise • Group Exercise Options • Healthy Walks• BACR Phase IV Classes (British Association of Cardiac Rehabilitation)
All customers also receive an inclusive membership card to the Leisure Centres with specialist benefi ts at a low cost.
HOW DO YOU REFER SOMEONE?3 EASY STEPS• Complete form (*subject to your assessment)
• Get patient to sign form
• Fax to Waterfront Leisure Centre on
020 8317 5011
The Healthwise team will contact your patient directly to arrange an appointment.
WHAT’S THE COST?Each individual will be offered a membership at one third of the cost of a standard membership. On successful completion of the programme this low cost membership is extended for a 3 year period. The membership includes a supervised and individually tailored exercise programme. After a one year period, the cost of the monthly membership will increase. Thereafter, an increase will occur on an annual basis for up to a three year period where a standard membership rate will apply. (Please note that the cost is paid by the customer and not your GP surgery).
HOW TO MAKE A REFERRAL
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THE REFERRAL PATHWAY
Refer back to Health Professional for advice as to further management
Patient not suitable or further information required
Patient is contacted by Healthwise to arrange a date for their 1st appointment
Patient booked for individual assessment with qualifi ed instructor
Refer back to Health professional for advice as to further management
Patient safe to exercise
Healthwise individual physical activity and education programme
Healthwise group physical activity and education programme
Patient continues to be physically active through further programmes
• Health professional assesses patient suitability for Healthwise scheme using inclusion/exclusion criteria
• Patient meets inclusion criteria
• Patient is ready to participate in exercise
• Health professional makes appropriate referral to Scheme Coordinator
Coordinator pre-screens every patient referral form to ensure suitability for scheme.
Patient NOT safe to exercise
HOW TO MAKE A CARDIAC REFERRAL
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HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME13
CHD PATIENT REFERRAL PATHWAY
GP/Cardiologist Assessment
Patient meets referral criteria
Patient does not meet referral criteria
BACR Phase IV SessionsInitial Assessment and Exercise Sessions supervised by
appropriately qualifi ed Phase IV Exercise Instructor
Following Phase III Cardiac Rehabilitation
Healthwise CHD form completed
IMPORTANT NOTEReferral form from Phase III to Phase IV is valid for 6 months from discharge from Phase III
Clinical Assessment (GP or other designated Health Professional)
To be completed in cases where:i) more than 6 months has elapsed since cardiac event ORii) more than 6 months since discharge from Phase III ORiii) CHD history but no recent acute event
IMPORTANT NOTEIf less than 6 months since acute event without clinical assessment or participation in Phase III redirect patient via Phase III
Phase III Referral Route 1Healthwise CHD Form
CHD GP Referral Route 2 Healthwise Referral Form
There are two different routes to making referrals for Cardiac Patients
PHASE III REFERRAL ROUTE 1Healthwise CHD Form
If the patient is less than 6 months post cardiac event, referral is via transition from Phase III to Phase IV Exercise – this referral will be made by a Phase III Professional ONLY.
CHD GP REFERRAL ROUTE 2Healthwise Referral Form (including Section 5. Cardiac History)
GP and other Health Professional CHD Exercise Referral Pathway. This referral route should be followed in cases where:i) more than 6 months has elapsed since cardiac event ORii) more than 6 months has elapsed since they were discharged from Phase III ORiii) CHD history but no recent event
Please refer to your Service Level Agreement for associated guidelines.
INCLUSION/ EXCLUSION CRITERIA
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HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME17
INCLUSION CRITERIAAll clients for the Healthwise Physical Activity Referral Scheme scheme must be:• Over 16• Greenwich Borough resident• Not currently active• Considering or ready to make a change to their physical activity levels
i.e. Contemplation, Preparation, or Action stageAnd with one or more of the following conditions:
CARDIOVASCULAR DESCRIPTION
ESTABLISHED CHD Stable Angina, Post MI, CABG, Angioplasty, Transplant, Valve Replacement, Stent, Permanent Pacemaker, Implanted Defi brillator, Heart Failure (only after Phase III Rehab and stable)
FAMILY HISTORY OF Female < 65; Male < 55 + two otherPREMATURE CHD CVD risk factor
HYPERTENSION Medication Controlled ≥ 140-180 SBP and or ≥ 90-100 DBP
INTERMITTENT No symptoms of cardiac dysfunctionCLAUDICATION/PVD
>10% CVD RISK OVER Multiple risk factors as identifi ed by Joint NEXT 10 YEAR British Society 2 guidelines (JBS2)
MENTAL HEALTH DESCRIPTION
DEPRESSION Mild to moderate
STRESS, ANXIETY Mild to moderate (dependent on medication)
INCLUSION CRITERIAMETABOLIC DESCRIPTION
HYPERLIPIDAEMIA Elevated total cholesterol ≥ 6.0mmol/l and/or raised triglycerides
OVERWEIGHT/OBESITY BMI ≥ 28
TYPE 1 DIABETES With adequate instructions regarding modifi cation of insulin dosage depending on timing of exercise. Advice given on warning signs and symptoms
TYPE 2 DIABETES Lifestyle & medication controlled
MUSCULOSKELETAL DESCRIPTION
BACK PAIN After back rehabilitation, referral from hospital Physiotherapist
CHRONIC FATIGUE SYNDROME Signifi cantly deconditioned due to longstanding symptoms
FIBROMYALGIA Associated impaired functional ability, poor physical fi tness, social isolation, neuroendocrine and autonomic system regulation disorders
OSTEOARTHRITIS/RHEUMATOID Moderate OA/RA with intermittent ARTHRITIS Arthritis mobility problems
OSTEOPENIA BMD greater than 1 SD and less than 2.5 SD below young adult mean
OSTEOPOROSIS BMD – 2.5 at spine, hip or forearm or >4 on fracture index with no history of previous low trauma fracture or history of falls
SURGERY (PRE/POST) General or Orthopaedic (after Consultant/Physiotherapist assessment)
ESTABLISHED CHD Stable Angina, Post MI, CABG, Angioplasty, Transplant, Valve Replacement, Stent, Permanent Pacemaker, Implanted Defi brillator, Heart Failure (only after Phase III Rehab and stable)
FAMILY HISTORY OF Female < 65; Male < 55 + two otherPREMATURE CHD CVD risk factor
HYPERTENSION Medication Controlled ≥ 140-180 SBP and or ≥ 90-100 DBP
INTERMITTENT No symptoms of cardiac dysfunctionCLAUDICATION/PVD
DEPRESSION Mild to moderate
STRESS, ANXIETY Mild to moderate (dependent on medication)
>10% CVD RISK OVER Multiple risk factors as identifi ed by Joint NEXT 10 YEAR British Society 2 guidelines (JBS2)
HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME19
INCLUSION CRITERIA
NEUROLOGICAL DESCRIPTION
NEUROLOGICAL CONDITIONS e.g. Young onset Parkinson’s Disease (stable), Multiple Sclerosis
STROKE / TIA > 3 months since stroke and < 1 yr ago. Stable CV symptoms, no assistance required
RESPIRATORY DESCRIPTION
ASTHMA/RESPIRATORY Grade 1-2 MRC Dyspnoea scale:PROBLEMS/COPD 1 – only get breathless with strenuous exercise 2 – short of breath when hurrying on the level or walking up a slight hill Patients Grade 3-5 MRC to be referred into Pulmonary Rehabilitation (PR) for a 4-10 week multidisciplinary programme before referral to Physical Activity Referral
Scheme (if appropriate)
EXCLUSION CRITERIA
DIAGNOSIS DESCRIPTION
ACUTE CORONARY EVENT/ < 6 months since acute event (referral to INTERVENTION/DIAGNOSIS Phase III only) CARDIAC DYSFUNCTION
CARDIAC DISEASE Unstable or uncontrolled
CLAUDICATION WITH CARDIACDYSFUNCTION
CLINICAL DIAGNOSIS OSTEOPOROSIS BMD greater than 2.5 at spine, hip or forearm, combined with one or more documented low trauma or fragility fractures
DIABETES TYPE I OR TYPE II With accompanying generalised neuropathy and untreated retinopathy (advanced)
ORTHOSTATIC HYPOTENSION SBP falls more than 20mmHg or DBP more than 10mmHg within 3 minutes of standing
SEVERE OA/RA With associated mobility problem
STROKE/TIA Recent, < 3 months ago
ASTHMA/RESPIRATORY Grade 1-2 MRC Dyspnoea scale:PROBLEMS/COPD 1 – only get breathless with strenuous exercise 2 – short of breath when hurrying on the level or walking up a slight hill Patients Grade 3-5 MRC to be referred into Pulmonary Rehabilitation (PR) for a 4-10 week multidisciplinary programme before referral to Physical Activity Referral
Scheme (if appropriate)
NEUROLOGICAL CONDITIONS e.g. Young onset Parkinson’s Disease (stable), Multiple Sclerosis
STROKE / TIA > 3 months since stroke and < 1 yr ago. Stable CV symptoms, no assistance required
HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME21
CONTRAINDICATIONS
RESTING SBP > 180MMHG: DBP > 100MMHG
UNCONTROLLED/UNSTABLE ANGINA
ACUTE UNCONTROLLED PSYCHIATRIC ILLNESS
EXPERIENCES SIGNIFICANT DROP IN BP DURING EXERCISE
UNCONTROLLED RESTING TACHYCARDIA > 100 BPM
SYMPTOMATIC HYPOTENSION
UNSTABLE OR ACUTE HEART FAILURE
UNCONTROLLED DIABETES
NEW OR UNCONTROLLED ARRHYTHMIAS
EXPERIENCES CHEST PAIN, DIZZINESS OR EXCESSIVE BREATHLESSNESS DURING EXERTION
FEBRILE ILLNESS
OTHER RAPIDLY PROGRESSING TERMINAL ILLNESS
ACUTE INFECTIONS/ILLNESS/FEVER
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
NEUROMUSCULAR, MUSCULOSKELETAL OR RHEUMATOID DISORDERS THAT ARE EXACERBATED BY EXERCISE
UNCONTROLLED MENTAL HEALTH CONDITION
CONTRAINDICATIONSSYMPTOMATIC SEVERE AORTIC STENOSIS
ACUTE PULMONARY EMBOLUS OR PULMONARY INFARCTION
ACUTE MYOCARDIITIS OR PERICARDITIS
SUSPECTED OR KNOWN DISSECTING ANEURYSM
CONTACT US
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HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME25
PARTICIPATING CENTRES:1 Arches Leisure Centre Trafalgar Road, Greenwich London SE10 9UX Tel: 020 8317 5000 ex 2802 2 Coldharbour Leisure Centre Chapel Farm Road, New Eltham, London SE9 3LX Tel: 020 851 8692
3 Eltham Centre 2 Archery Road, Eltham, London SE9 1HA Tel: 020 8921 4344
4 Thamesmere Leisure Centre Thamesmere Drive, Thamesmead, London SE28 8RE Tel: 020 8311 1119
5 Waterfront Leisure Centre High Street, Woolwich, London SE18 6DL
Tel: 020 8317 5000 ex 2130
CONTACT USShould you have any queries relating to the Healthwise Scheme, please do not hesitate to contact:
HEALTHWISE COORDINATOR Waterfront Leisure Centre, High Street, Woolwich, London SE18 6DLTelephone: 020 8317 5000 ext. 2130Fax: 020 8317 5011 Email: healthwise.greenwich@gll.org Map of Centres within Greenwich
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APPENDICIES
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www.gll.org
HEALTHWISEPHYSICAL ACTIVITY REFERRAL SCHEME
How to make a referralPlease remember that the Healthwise Physical Activity Referral Scheme has been designed for those individuals who have not had access to Leisure Centres previously. It is important you follow the referral procedure as closely as possible in order to ensure that your patient’s referral is processed promptly.
At the end of your appointment with a patient, please ensure that you have followed this procedure:
✓ The Patient being referred is a low to medium risk patient and is suitable to undertake a physical activity programme.
✓ ALL sections of the referral form have been completed in full (with specific detail given to previous medical history and medication including ALL contact details and signatures).
✓ The Patient understands that they are being referred to an exercise referral programme for a 13-26 week period, which is not a one to one training service.
✓ The Patient understands that there will be assessments throughout the programme that are compulsory to their continuation on the Healthwise programme.
✓ The Patient understands that they will need to make a payment to the Leisure Centre for this programme.
✓ The form has been faxed through to the Waterfront Leisure Centre on: 020 8317 5011
For a CHD Referral please refer to the Referrers Manual
www.gll.orgWorking in partnership with www.gll.orgwww.gll.org
For more information relating to Inclusion and Exclusion Criteria, please refer to your Referrers Manual.
CONTACT USFor more information about Healthwise, please feel free to contact the team at the Waterfront Leisure Centre, High Street,Woolwich, London SE18 6DL
Tel: 020 8317 5000 ext. 2130 Fax: 020 8317 5011Email: healthwise.greenwich@gll.org
INCLUSION CRITERIA EXCLUSION CRITERIA
CONTRAINDICATIONSRESTING SBP > 180MMHG: DBP > 100MMHG
UNCONTROLLED/UNSTABLE ANGINA
ACUTE UNCONTROLLED PSYCHIATRIC ILLNESS
EXPERIENCES SIGNIFICANT DROP IN BP DURING EXERCISE
UNCONTROLLED RESTING TACHYCARDIA > 100 BPM
SYMPTOMATIC HYPOTENSION
UNSTABLE OR ACUTE HEART FAILURE
UNCONTROLLED DIABETES
NEW OR UNCONTROLLED ARRHYTHMIAS
EXPERIENCES CHEST PAIN, DIZZINESS OR EXCESSIVEBREATHLESSNESS DURING EXERTION
FEBRILE ILLNESS
OTHER RAPIDLY PROGRESSING TERMINAL ILLNESS
ACUTE INFECTIONS/ILLNESS/FEVER
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
NEUROMUSCULAR, MUSCULOSKELETAL OR RHEUMATOID DISORDERS THAT ARE EXACERBATED BY EXERCISE
UNCONTROLLED MENTAL HEALTH CONDITION
SYMPTOMATIC SEVERE AORTIC STENOSIS
ACUTE PULMONARY RY R EMBOLUS OR PULMONARY RY R INFAFAF RCTION
ACUTE MYOCARDIITIS OR PERICARDITIS
SUSPECTED OR KNOWN DISSECTING ANEURYSM
Established CHD
Intermittent Claudication/
Depression
Chronic Fatigue
Rheumatoid Arthritis
Conditions
Cardiac Disease
Claudication with Cardiac
Clinical Diagnosis
HEALTHWISE CHD REFERRAL FORM(TO BE COMPLETED BY PHASE III CARDIAC PROFESSIONAL. PLEASE COMPLETE IN BLOCK CAPITALS AND COMPLETE ALL ITEMS)
Has the client attended Phase III – Yes No If No please give reason
If Yes, Where Date commenced: Date completed:
6. PHASE III
5. MEDICAL HISTORY ORY OR (PLEASE NOTE ALL RELEVANT MEDICAL CONDITIONS)
3. CURRENT MEDICATION (PLEASE ATTACH PRESCRIPTION LIST / ADDITIONAL SHEET)Ace Inhibitor Calcium Channel Blocker Nitrate
Anti-arrhyhmic Clopidogrel Statin
Aspirin Diuretic Warfarin
Beta Blocker GTN Other:
4. INVESTIGATIONS (IF APPLICABLE)
ETT Yes No Date: Result Full Bruce Modified Bruce
LV Function Good Moderate Poor Ongoing Investigations
Yes No Date:
unction Good oderate Poor
ull Bruce Yes No Date:
PATIENT DETAILS PATIENT DETAILS PName:
Address:
Post Code:
Telephone (home): Telephone (home): T
Telephone (work): Telephone (work): T
D.O.B:
Ethnicity:
Occupation:
Emergency contact:
REFERRER’S DETAILS
Name:
Profession:
Surgery/Dept:
Address:
Postcode:
Telephone: Telephone: T
Email address:
GP Name (if not the referrer above):
Surgery/Dept:
MEDICAL DETAILS (*ITEMS ARE COMPULSORY AND MUST BE COMPLETED, PLEASE CIRCLE RISK FACTORS IF APPLICABLE)
1. CURRENT STATUS – CHD RISK FK FK A FA F CTORS (RF)*BP *Resting HR *Height (cm) *Weight (kg) *BMI
Sedentary Smoker Raised Cholesterol Stress Excess Alcohol
2. CARDIAC HISTORYORYORMI Date: Angioplasty/Stent Date: CABG Date:
Current Angina (at rest/exertion) Current Dyspnoea Arrhythmias
Heart Failure ICD/Pacemaker (detail) Other Event/s Date:
7. PREFERRED SITE: ARCHES COLDHARBOUR ELTHAM THAMESMERE WATE WATE W RFRONT
I have discussed the Healthwise scheme with this patient
I believe the patient is ready to participate in a physical activity programme
The patient exhibits no contra indications to exercise (as indicated on the protocol)
The patient is clinically stable
The patient is compliant with medication
The patient is not awaiting medical investigation /treatment (see protocol)
The information on this form is an accurate representation of this Patient’s health status. If I become aware that this status changes, I will endeavour to inform the Healthwise Coordinator
REFERRER/PATIENT CR/PATIENT CR ONSENT (YOU MUST TICK EACH BOX)
Patient signature:.........................................Date..............
Print Name: .....................................................................
Referrer signature:.........................................Date...........
Print Name: .....................................................................
I agree for the information on this form to be passed onto the
Healthwise PARS team
Please note: This form should be completed and signed by both Referrer and Patient and then faxed to:Waterfront Leisure Centre, High Street, Woolwich, SE18 6DL. Fax: 020 8317 5011 Tel: 020 8317 5000 ext. 2130
HEALTHWISE REFERRAL FORM(PLEASE COMPLETE IN BLOCK CAPITALS. ALL ITEMS IN THIS SECTION MUST BE COMPLETED)
MEDICAL DETAILS (*ITEMS ARE COMPULSORY AND MUST BE COMPLETED, PLEASE CIRCLE RISK FACTORS IF APPLICABLE)
PATIENT DETAILS Name:
Address:
Post Code:
Telephone (home): Telephone (home): T
Telephone (work): Telephone (work): T
D.O.B:
Ethnicity:
Occupation:
Emergency contact:
REFERRER’S DETAILSName:
Profession:
Surgery/Dept:
Address:
Postcode:
Telephone: Telephone: T
Email address:
GP Name (if not the referrer above):
Surgery/Dept:
1. CURRENT STATUS – CHD RISK FK FK ACT FACT F ORS (RF)*BP *Resting HR *Height (cm) *Weight (kg) *BMI
Sedentary Smoker Raised Cholesterol Stress Excess Alcohol
2. REASON FOR REFERRAL (PLEASE REFER TO INCLUSION CRITERIA)
3. ADDITIONAL MEDICAL CONDITIONS PAST AND PRESENT
4. CURRENT MEDICATION (PLEASE ATTACH PRESCRIPTION LIST / ADDITIONAL SHEET)
Arthritis (Osteo / Rheumatoid) Established CHD (state in section 5) Osteopenia
Asthma / COPD Family CHD (premature) + 2 RF Osteoporosis (no history fracture)
Back Pain (referral from Physio) Fibromyalgia Overweight / Obesity (BMI >28)
Chronic Fatigue Syndrome Hyperlipidaemia (state levels) Stress / Anxiety
Depression Hypertension Stroke / TIA Date:
Diabetes Type Type T I (state HbA1c) Intermittent Claudication / PVD Surgery – Pre / Post Date:
Diabetes Type Type T II (state HbA1c) Neurological Conditions (detail below) >10+ CVD risk (next 10 years)
5. CARDIAC HISTORY ORY OR (IF APPLICABLE - ESTABLISHED CHD)
MI Date: Angioplasty / Stent Date: CABG Date:
Current Angina (at rest exertion) Current Dyspnoea Arrhythmias
Heart Failure ICD / Pacemaker (detail) Other Event/s Date:
Cardiac Investigations (if applicable / and or available) Angiogram: Yes No Date:
ETT Yes No Date: Result (Full / Modified Bruce) LV LV L Function Good Moderate Poor
Has the client attended Phase III Yes No If yes, Date Completed:
6. PREFERRED SITE: ARCHES COLDHARBOUR ELTHAM THAMESMERE WATE WATE W RFRONT
I have discussed the Healthwise scheme with this patient
I believe the patient is ready to participate in a physical activity programme
The patient exhibits no contra indications to exercise (as indicated on the protocol)
The patient is clinically stable
The patient is compliant with medication
The patient is not awaiting medical investigation /treatment (see protocol)
The information on this form is an accurate representation of this Patient’s health status. If I become aware that this status changes, I will endeavour to inform the Healthwise Coordinator
REFERRER/R/R P/P/ ATIENT PATIENT P CONSENT (YOU MUST TICK EACH BOX)
Patient signature:.........................................Date..............
Print Name: .....................................................................
Please note: This form should be completed and signed by both Referrer and Patient and then faxed to:Waterfront Leisure Centre, High Street, Woolwich, SE18 6DL. Fax: 020 8317 5011 Tel: 020 8317 5000 ext. 2130
Referrer signature:.........................................Date...........
Print Name: .....................................................................
I agree for the information on this form to be passed onto the
Healthwise PARS team
HEALTHWISE PHYSICAL ACTIVITY REFERRAL SCHEME33
NOTES NOTES
Leisure Centres in Greenwich owned and supported by Greenwich Council
HEALTHWISE COORDINATORWaterfront Leisure Centre, High Street, Woolwich, London SE18 6DLTelephone: 020 8317 5000 ext. 2130Fax: 020 8317 5011 Email: healthwise.greenwich@gll.org
Registered Address: GLL (Greenwich Leisure Limited), Middlegate House, The Royal Arsenal, London SE18 6SX
I.P.S. Registration Number: 27793R Inland Revenue Charity Number: XR43398
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