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Healthy Lifestyle support is for:
Myself
Someone else
Your details:
First name(s)
Last name
Gender
Male
Female
Prefer not to say
Indeterminate (unable to be classified as either male or female)
Date of birth
Contact number
Mobile number
Email address
Postal address
Postcode
GP name (if known)
GP practice (if known)
Please tick the box if any of these apply to you:
Long Term Condition
Mental Health problem
Learning disability
Physical disability
None
Additional comments
How did you find out about Healthy Lifestyles?
How did you find out about Healthy Lifestyles?
Support required in relation to
(tick as many boxes as apply):
Smoking
Alcohol
Healthy eating &
Healthy eating &
Weight management
Physical activity
Height (cm)
or
feet
inches
Weight (kg)
or
st
lbs
BMI
(please enter height and weight)
Your BMI is
0
Referrer’s details:
Your name
Your organisation
Your job title
Your email
Your tel no
Support required in relation to
(tick as many boxes as apply):
Smoking
Alcohol
Weight management
Physical activity
Please select preferred Service for weight management
Healthy Lifestyles 1:1 Support
Slimming World
Height (cm)
or
feet
inches
Weight (kg)
or
st
lbs
BMI
(please enter height and weight)
Your BMI is
0
Client’s details:
First name(s)
Last name
Gender
Male
Female
Prefer not to say
Indeterminate (unable to be classified as either male or female)
Date of birth
Contact number
Mobile number
Postal address
Email address
Postcode
Do any of these apply to you?
Long Term Condition
Mental Health problem
Learning disability
Physical disability
None
Known issues/additional comments
NHS Number (if known)
NHS Number (if known)
I do not know my NHS number
I do not know my NHS number
Ethnic Category
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated
Not Known
Ethnic Category
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated
Not Known
Employment Status
Employed
Unemployed and actively seeking work
Undertaking full or part time education or training as a student and not working or actively seeking work
Long term sick or disabled, or receiving government sickness and disability benefits
Looking after the family or home as a homemaker and not working or actively seeking work
Not receiving government sickness and disability benefits and not working or actively seeking work
Unpaid voluntary work and not working or actively seeking work
Retired
Not stated
Employment Status
Employed
Unemployed and actively seeking work
Undertaking full or part time education or training as a student and not working or actively seeking work
Long term sick or disabled, or receiving government sickness and disability benefits
Looking after the family or home as a homemaker and not working or actively seeking work
Not receiving government sickness and disability benefits and not working or actively seeking work
Unpaid voluntary work and not working or actively seeking work
Retired
Not stated
Midwife support:
I'm Currently Pregnant
I've given birth and my child is under the age of 2
Neither
My named midwife
Baby delivery date
Clear
1:1 support is only available for stop smoking and/or weight management if your BMI is between 30 and 40.
To check if your BMI is in range, tick Healthy Eating below and fill in your weight and height. If your BMI is over 40 you are still eligible for group support.
My named midwife
Baby delivery date
Clear
1:1 support is only available for stop smoking and/or weight management if your BMI is between 30 and 40.
To check if your BMI is in range, tick Healthy Eating below and fill in your weight and height. If your BMI is over 40 you are still eligible for group support.
Disability Self Report (tick any that apply)
Long Term Condition
Mental Health Condition
Learning Disability
Physical Disability
Referral Source
Acute hospital Inpatient/Outpatient Department
Ambulance Service
Asylum Service
Care home
Carer/Relative
Community Health Service (same or other Health Care provider)
Courts
Dental Practice
Educational Establishment
Emergency Care Department (including Minor injuries and Walk in Centres)
Employer
General Medical Practitioner Practice
Hospice
Independent Sector
Local Authority Social Services
Mental Health Service
National Screening Programme
Pharmacy
Police
Prison Health Service
Probation Service
Self Referral
Telephone or Electronic Access Service
Voluntary Sector
Midwife support:
Antenatal
Postnatal
Neither
Named midwife
Named midwife email
Baby delivery date
Clear
1:1 support available for Smoking Cessation and/or Weight Management if BMI is between 30 and 40
Named midwife
Named midwife email
Baby delivery date
Clear
1:1 support available for Smoking Cessation and/or Weight Management if BMI is between 30 and 40
Disability Type
Behavioural and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (learning disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self-Care and Continence
Progressive Conditions and Physical Health (Such as HIV, Cancer, Multiple sclerosis, fits etc)
Sight
Speech
Other
No Disability
Not Stated (person asked but declined to provide a response)
Sexual Orientation
Sexually Attracted to neither Male nor Female sex
Bisexual
Male homosexual
Female homosexual
Sexual Orientation Unknown
Undecided about sexual orientation
Heterosexual
Do not wish to answer
Belief System
Pagan
Buddhist
Muslim
Sikh
Bahai
Jain
Zoroastrian
Agnostic
Hindu
Jewish
Christian
Not Religious
Religious belief not listed
Religion unknown
Do not wish to answer
Client consent (to be confirmed by client)
I consent to being referred to the Gloucestershire Healthy Lifestyles Service, the nature and purpose of which has been explained by my referrer.
I consent to the release of relevant personal information about myself to the Gloucestershire Healthy Lifestyles Service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.
I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.
Consent to process personal data
Please tick this box if you the individual has consented to this service’
Introduction
Your data is required to:
Assist us in delivering the most suitable lifestyles services to meet your specific needs
Accurately monitor your progress throughout the programme
Ensure sure that our services remain current and effective
Your data may be used by the following subcontractors for the delivery of our services:
Slimming World
To allow us to develop anonymised reports for issuing to our commissioners, Gloucestershire City Council, and the Department of Health
Enabling us to offer you a better service by sharing your health information with your GP
Acceptance
I consent for my personal details to be held by Gloucestershire Healthy Lifestyle Services. I understand the service will hold my personal data for up to five years, which will allow me to re-enter the service during that time. I understand I have the right to ask for my data to be deleted from the service records at any time. I understand that anything I disclose to a health coach will be treated in the strictest confidence and will only be shared with other services with my permission or for legal reasons that ICE Creates Ltd are obliged to uphold.
I consent for the service to use my details for statistical and analysis purposes only, and understand that my confidentiality will be maintained always, and all information will be stored in accordance with ICE Creates Ltd data protection policy and procedures, and that my personal identifiable details will not be used in any reports without my permission.
Obtaining Consent
We have checked that consent is one of the appropriate lawful basis for processing and have made the request for consent prominent and separate from our terms and conditions when we ask people to positively opt in.
We don’t use pre-ticked boxes, or any other type of consent by default in fact we use clear, plain language that is easy to understand and inform you specifically why we want the data and what we’re going to do with it.
You have the right to withdraw your consent without detriment to you and you have the right to refuse to consent without detriment. You also have the right to request a copy of the information we hold about you in an easy to read and transferable format
If you refuse to provide consent it will be difficult for us to provide a lifestyle services to you for clinical and safety reasons, in addition, we must obtain and maintain accurate details about you.
Managing Consent
We record consent by storing when and how we were provided with your consent and exactly what you were told at the time.
We will not share your data with other service providers without your agreement and your data will not be transferred outside of the UK.
We regularly review consent to check that the relationship, the processing and the purposes have not changed.
We have processes in place to refresh consent at appropriate intervals. It is an easy process for individuals to withdraw their consent at any time, and we act on withdrawals of consent as soon as we can. Additionally, we don’t penalise individuals who wish to withdraw consent.
For the individual being referred
I can obtain further information about how my personal data is processed on the HLS privacy notice, which includes the right to withdraw consent to this referral and sharing myprogress with the referrer. This can be reached at hlsglos.org/privacy and a copy is also available at the Healthy Lifestyles Gloucestershire Office upon request.
I recommend for the above person to be referred to the Gloucestershire Healthy Lifestyles Service to receive onward signposting and support.
I confirm that I have assessed this person, and to my knowledge there is no medical reason why he/she should not be referred.
I confirm that I have discussed this referral, and the reasoning for it, with the person named above
As I have been referred to the weight management referral scheme, the nature and purpose of which has been explained by my referrer. I understand that this will require the release of relevant personal information about myself to the Gloucestershire Healthy Lifestyle Service (HLS) and Slimming World (SW).
I would like to be kept up to date on the progress of this referral should the subject give their consent
Client consent
I consent to being referred to the Gloucestershire Healthy Lifestyles Service. The nature and purpose of which has been explained by my referrer.
I consent to the release of relevant personal information about myself to the Gloucestershire Healthy Lifestyles Service. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controller is my referrer.
I understand that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information.
Consent to process personal data
Please tick this box if you consent to this service
Read our referral privacy policy
here
Please note that we aim to contact you within two full working days of receiving your information.
Thanks for completing this assessment