Counterweight - Self Referral Form

1. Personal Details

You can self refer to the programme using the form below, or for more info contact the Healthy Communities team on: 01224 507701 or email: activelifestyles@sportaberdeen.co.uk

Your Contact Details: *

Forename	*
Preferred name	*
Surname	*
Date of birth	*

Do you have a physical or mental health condition or illness lasting or expected to last 12 months or more?

Yes
No
Prefer not to say

Do you consider yourself to have a disability?

Yes
No
Prefer not to say

Do you consider yourself to have a caring role? (this is anyone of any age who helps a relative, friend or neighbour who cannot manage without their support and has taken on an unpaid caring role in addition to their existing commitments)

Yes
No
Prefer not to say

Address: *

Address 1	*
Address 2	*
Town	*
Postcode	*
Telephone Number	*
Mobile Number	*
Email address	*

Emergency contact *

Name	*
Telephone Number	*
Relationship to participant	*

Do you have any of the medical conditions listed below? *

	Yes	No
Heart Conditions (e.g. heart attack)	Heart Conditions (e.g. heart attack) Yes	Heart Conditions (e.g. heart attack) No
Breathing conditions (e.g. asthma)	Breathing conditions (e.g. asthma) Yes	Breathing conditions (e.g. asthma) No
Diabetes	Diabetes Yes	Diabetes No
Neurological condition (e.g. stroke)	Neurological condition (e.g. stroke) Yes	Neurological condition (e.g. stroke) No
Epilepsy	Epilepsy Yes	Epilepsy No
Surgery (e.g. joint replacement)	Surgery (e.g. joint replacement) Yes	Surgery (e.g. joint replacement) No
Hearing / visual difficulty	Hearing / visual difficulty Yes	Hearing / visual difficulty No
Cognitive impairment (e.g. dementia)	Cognitive impairment (e.g. dementia) Yes	Cognitive impairment (e.g. dementia) No
Bone, muscle, joint condition (e.g. osteoporosis)	Bone, muscle, joint condition (e.g. osteoporosis) Yes	Bone, muscle, joint condition (e.g. osteoporosis) No
Mental health condition	Mental health condition Yes	Mental health condition No
Cancer	Cancer Yes	Cancer No

Other relevant information

Health screening questionnaire *

	Yes	No
Has your doctor ever said you have a heart condition and should only do physical activity recommended by a doctor?	Has your doctor ever said you have a heart condition and should only do physical activity recommended by a doctor? Yes	Has your doctor ever said you have a heart condition and should only do physical activity recommended by a doctor? No
Do you feel pain in your chest when you do physical activity?	Do you feel pain in your chest when you do physical activity? Yes	Do you feel pain in your chest when you do physical activity? No
In the past month, have you had pain in your chest when you are not doing physical activity?	In the past month, have you had pain in your chest when you are not doing physical activity? Yes	In the past month, have you had pain in your chest when you are not doing physical activity? No
Do you lose your balance because of dizziness or do you ever lose consciousness?	Do you lose your balance because of dizziness or do you ever lose consciousness? Yes	Do you lose your balance because of dizziness or do you ever lose consciousness? No
Has your doctor ever said that you have had a stroke?	Has your doctor ever said that you have had a stroke? Yes	Has your doctor ever said that you have had a stroke? No
Do you have any active eating disorders?	Do you have any active eating disorders? Yes	Do you have any active eating disorders? No
Are you pregnant or breastfeeding?	Are you pregnant or breastfeeding? Yes	Are you pregnant or breastfeeding? No
Do you have a Body Mass Index (BMI) that is in the overweight or obese category?	Do you have a Body Mass Index (BMI) that is in the overweight or obese category? Yes	Do you have a Body Mass Index (BMI) that is in the overweight or obese category? No
Are you ready to make a change?	Are you ready to make a change? Yes	Are you ready to make a change? No

How active are you currently? E.g. activity could be walking around the block daily/gardening or housework/attending an exercise class once a week

Privacy Notice *

	Yes	No
I have been informed about the programme and wish to join an exercise group	I have been informed about the programme and wish to join an exercise group Yes	I have been informed about the programme and wish to join an exercise group No
I agree to my information being stored securely and accessed confidentially by the Exercise Instructors	I agree to my information being stored securely and accessed confidentially by the Exercise Instructors Yes	I agree to my information being stored securely and accessed confidentially by the Exercise Instructors No
I consent to receiving email updates from Sport Aberdeen (you can withdraw consent at any time by contacting activelifestyles@sportaberdeen.co.uk or 01224 507701)	I consent to receiving email updates from Sport Aberdeen (you can withdraw consent at any time by contacting activelifestyles@sportaberdeen.co.uk or 01224 507701) Yes	I consent to receiving email updates from Sport Aberdeen (you can withdraw consent at any time by contacting activelifestyles@sportaberdeen.co.uk or 01224 507701) No
I understand that information will be held at Sport Aberdeen for the purposes of my participation in the programme	I understand that information will be held at Sport Aberdeen for the purposes of my participation in the programme Yes	I understand that information will be held at Sport Aberdeen for the purposes of my participation in the programme No
I have read the Sport Aberdeen Privacy Notice www.sportaberdeen.co.uk/sport-aberdeen/privacy-policy	I have read the Sport Aberdeen Privacy Notice www.sportaberdeen.co.uk/sport-aberdeen/privacy-policy Yes	I have read the Sport Aberdeen Privacy Notice www.sportaberdeen.co.uk/sport-aberdeen/privacy-policy No