HEALTHWISE

PHYSICAL ACTIVITY REFERRAL SCHEME

Working in partnership with
REFERRERS MANUAL
HEALTHWISE
PHYSICAL ACTIVITY REFERRAL SCHEME 3
CONTENTS
WELCOME
Welcome Message 04
GENERAL INFORMATION
What is Healthwise? 06
Whos running it and where?
Who should you refer?
What activities are available?
How do you refer someone?
Whats the cost?
HOW TO MAKE A REFERRAL
The Referral Pathway 10
HOW TO MAKE A CARDIAC REFERRAL
CHD Patient Referral Pathway 12
Cardiac Referral Forms Route 1 & 2
INCLUSION/EXCLUSION CRITERIA
Inclusion Criteria 16
Exclusion Criteria
Contraindications
CONTACT US
Contact Details 24
APPENDICIES
How to make a referral 28
Healthwise Referral Form
Healthwise Cardiac Referral Form
Notes
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6
GENERAL
INFORMATION
WELCOME
Message 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 nd
a suitable way to get 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 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 nd that the Leisure Centres offer great facilities for
all and we are certain that we can help individuals get 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 SCHEME 7
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.
WHOS 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 qualied team based in the Leisure
Centres dedicated to the provision of safe and effective exercise.
All facilitators are Level 3 exercise referral qualied as a minimum.
WHO SHOULD YOU REFER?
(OVER 16S ONLY)
Healthwise is designed for Greenwich residents who are currently not active,
but would benet 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 patients 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 condence 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 benets 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.
WHATS 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 qualied 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 SCHEME 13
CHD PATIENT REFERRAL PATHWAY
GP/Cardiologist
Assessment
Patient
meets referral
criteria
Patient does
not meet
referral
criteria
BACR Phase IV Sessions
Initial Assessment and Exercise Sessions supervised by
appropriately qualied Phase IV Exercise Instructor
Following Phase III Cardiac
Rehabilitation
Healthwise CHD form completed
IMPORTANT NOTE
Referral 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 OR
ii) more than 6 months since
discharge from Phase III OR
iii) CHD history but no recent
acute event
IMPORTANT NOTE
If less than 6 months since acute
event without clinical assessment
or participation in Phase III redirect
patient via Phase III
Phase III Referral Route 1
Healthwise 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 1
Healthwise 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 2
Healthwise 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 OR
ii) more than 6 months has elapsed since they were discharged
from Phase III OR
iii) 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 SCHEME 17
INCLUSION CRITERIA
All 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 stage
And 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 Debrillator, Heart Failure
(only after Phase III Rehab and stable)
FAMILY HISTORY OF Female < 65; Male < 55 + two other
PREMATURE CHD CVD risk factor
HYPERTENSION Medication Controlled 140-180 SBP and or
90-100 DBP
INTERMITTENT No symptoms of cardiac dysfunction
CLAUDICATION/PVD
>10% CVD RISK OVER Multiple risk factors as identied 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 CRITERIA
METABOLIC DESCRIPTION
HYPERLIPIDAEMIA Elevated total cholesterol 6.0mmol/l and/or
raised triglycerides
OVERWEIGHT/OBESITY BMI 28
TYPE 1 DIABETES With adequate instructions regarding modication
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 Signicantly deconditioned due to
longstanding symptoms
FIBROMYALGIA Associated impaired functional ability,
poor physical 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 Debrillator, Heart Failure
(only after Phase III Rehab and stable)
FAMILY HISTORY OF Female < 65; Male < 55 + two other
PREMATURE CHD CVD risk factor
HYPERTENSION Medication Controlled 140-180 SBP and or
90-100 DBP
INTERMITTENT No symptoms of cardiac dysfunction
CLAUDICATION/PVD
DEPRESSION Mild to moderate
STRESS, ANXIETY Mild to moderate (dependent on medication)
>10% CVD RISK OVER Multiple risk factors as identied by Joint
NEXT 10 YEAR British Society 2 guidelines (JBS2)
HEALTHWISE
PHYSICAL ACTIVITY REFERRAL SCHEME 19
INCLUSION CRITERIA
NEUROLOGICAL DESCRIPTION
NEUROLOGICAL CONDITIONS e.g. Young onset Parkinsons 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 CARDIAC
DYSFUNCTION
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 Parkinsons Disease (stable),
Multiple Sclerosis
STROKE / TIA > 3 months since stroke and < 1 yr ago.
Stable CV symptoms, no assistance required
HEALTHWISE
PHYSICAL ACTIVITY REFERRAL SCHEME 21
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
CONTRAINDICATIONS
SYMPTOMATIC 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 SCHEME 25
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 US
Should 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 6DL
Telephone: 020 8317 5000 ext. 2130
Fax: 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
HEALTHWISE
PHYSICAL ACTIVITY REFERRAL SCHEME
How to make a referral
Please 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 patients 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 specic 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
Working in partnership with
For more information relating to Inclusion and Exclusion
Criteria, please refer to your Referrers Manual.
CONTACT US
For 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 5011
Email: healthwise.greenwich@gll.org
INCLUSION CRITERIA EXCLUSION CRITERIA
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
PERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY
NEUROMUSCULAR, MUSCULOSKELETAL OR RHEUMATOID
DISORDERS THAT ARE EXACERBATED BY EXERCISE
UNCONTROLLED MENTAL HEALTH CONDITION
SYMPTOMATIC SEVERE AORTIC STENOSIS
ACUTE PULMONARY RR EMBOLUS OR PULMONARY RR INFA FF RCTION
ACUTE MYOCARDIITIS OR PERICARDITIS
SUSPECTED OR KNOWN DISSECTING ANEURYSM
Established CHD
Family History o
Premature CHD
Hypertension
Intermittent Claudication/
P\D
> 10 C\D risk over
next 10 year
Depression
Stress, /nxiety
Hyperlipidaemia
0verweight/0besity
Type 1 Diabetes
Type 2 Diabetes
Back Pain
Chronic Fatigue
Syndrome
Fibromyalgia
0steoarthritis/
Rheumatoid Arthritis
0steopenia
0steoporosis
Surgery (Pre/Post)
Neurological
Conditions
Stroke / T/
/sthma/Respiratory
Problems/C0PD
/cute Coronary Event/
ntervention/Diagnosis
(within the last 6 months
< 6 months ago)
Cardiac Disease
(unstable)
Claudication with Cardiac
Dysunction
Clinical Diagnosis
0steoporosis
Diabetes Type or Type
(advanced)
0rthostatic Hypotension
Severe 0//R/
Stroke/T/
(recent, < 3 months ago)
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 OR 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 Modied Bruce
LV Function Good Moderate Poor Ongoing Investigations
Yes No Date:
unction Good oderate Poor
ull Bruce Yes No Date:
PATIENT DETAILS PP
Name:
Address:
Post Code:
Telephone (home): TT
Telephone (work): TT
D.O.B:
Ethnicity:
Occupation:
Emergency contact:
REFERRERS DETAILS
Name:
Profession:
Surgery/Dept:
Address:
Postcode:
Telephone: TT
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 F KK A FF CTORS (RF)
*BP *Resting HR *Height (cm) *Weight (kg) *BMI
Sedentary Smoker Raised Cholesterol Stress Excess Alcohol
2. CARDIAC HISTORY OR OR
MI 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 WW 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
Patients health status. If I become aware that this status changes,
I will endeavour to inform the Healthwise Coordinator
REFERRER/PATIENT C RR 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): TT
Telephone (work): TT
D.O.B:
Ethnicity:
Occupation:
Emergency contact:
REFERRERS DETAILS
Name:
Profession:
Surgery/Dept:
Address:
Postcode:
Telephone: TT
Email address:
GP Name (if not the referrer above):
Surgery/Dept:
1. CURRENT STATUS CHD RISK F KK ACT FF 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 TT I (state HbA1c) Intermittent Claudication / PVD Surgery Pre / Post Date:
Diabetes Type TT II (state HbA1c) Neurological Conditions (detail below) >10+ CVD risk (next 10 years)
5. CARDIAC HISTORY OR 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 / Modied Bruce) LV LL Function Good Moderate Poor
Has the client attended Phase III Yes No If yes, Date Completed:
6. PREFERRED SITE: ARCHES COLDHARBOUR ELTHAM THAMESMERE WATE WW 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
Patients health status. If I become aware that this status changes,
I will endeavour to inform the Healthwise Coordinator
REFERRER/ RR P // ATIENT PP 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 SCHEME 33
NOTES NOTES
Leisure Centres in Greenwich owned
and supported by Greenwich Council
HEALTHWISE
COORDINATOR
Waterfront Leisure Centre, High Street,
Woolwich, London SE18 6DL
Telephone: 020 8317 5000 ext. 2130
Fax: 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