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GP Referral Programme

Health Declaration

Please fill out the following form
in order to participate in our GP Referral Programme. Please note that this 12-week programme is £75 payable in advance.

First name

Last name

Email

Date of Birth

Phone

Referral Reasons

Heart condition

Obesity

Hypertension

Hyper Cholesterol

CHD - Angina Pectoris

Asthma

Stress

Anxiety

Mild Depression

Osteoperosis

Osteoarthritis

Do you have any other medical conditions which may affect your ability to take part in an exercise session

Heart condition

Diabetes

Circulation condition

Respiratory condition

History of falls

RA/OA

History of fracture

Osteoperosis

History of previous joint replacement

MS/CVA/PD

Rheumatoid arthritis

Other forms of arthritis

Back pain

Joint replacement

Please specify

Please list any medication you are on for the referred condition or any others that could affect your wellbeing on the course:

Please tick if yes

Do you smoke?

Do you drink alcohol

Do you exercise for more than 30 mins per week

Do you eat 5 portions of fruit and veg per day

Do you ever:

Fear of falling

Feeling unstable

History of falls

Low bone density

Initials

I consent to the above information being passed to the exercise specialist and agree to disclose any other information regarding my health that may affect my ability to exercise. I agree to returning this form on day 1 to participate on the course and reading the Atrium Fitness terms and conditions and club rules and etiquette before enrolling onto this course. I am committed and have purchased by 12 week course with reception.

I accept the general terms & conditionsView terms of use

I accept the terms & conditions of the GP Exercise Referral SchemeView terms of use

Thanks for submitting!

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