Self-referral form

Please read the following information carefully before you complete this form.

WHO CAN JOIN OUR CARDIAC REHAB EXERCISE CLASSES?

✔ People who have completed a hospital-based “Phase 3” Cardiac Rehab programme.

(If you have completed Phase 3 within the past 6 months, please ask your hospital team for a referral and do not complete this form)

✔ People referred by their GP surgery (including referrals from nurses, physios etc).

✔ Anyone with a diagnosed heart condition or who is at risk of developing heart disease. Key risks include: smoking, obesity, high blood pressure, high cholesterol, diabetes, and a family history of heart disease.

✔ Partners, carers, relatives or friends who wish to provide support and take part.

See overleaf for class locations and times.

PLEASE DO NOT COMPLETE THIS FORM IF YOU HAVE ANY OF THE FOLLOWING:

✗ Unstable angina

✗ Unstable or acute heart failure

✗ New or uncontrolled irregular heartbeat

✗ Resting heart rate above 100 beats per minute

✗ Resting systolic blood pressure above 180mmHg or diastolic blood pressure above 100mmHg

✗ Drop in blood pressure during exercise that makes you feel dizzy or faint

✗ High temperature/fever

✗ Unstable diabetes

These conditions mean that you are not yet ready to exercise.

Please fill in all sections of this form, including the questionnaire, privacy statement and declaration of consent below. You must complete all items marked with an asterisk.

PERSONAL DETAILS

Do you declare a disability? *

EMERGENCY CONTACT DETAILS

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

Please read the following questions carefully and answer each one by ticking Yes or No.

1. Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
2. Do you feel pain in your chest when you do physical activity? *
3. In the past month, have you had chest pain when you were not doing physical activity? *
4. Do you lose your balance because of dizziness, or do you ever lose consciousness? *
5. Do you have a bone or joint problem that could be worsened by a change in your physical activity? *
6. Is your doctor currently prescribing drugs (for example, water tablets/diuretics) for your blood pressure or heart condition? *
7. Do you know of any other reason why you should not do physical activity? *

Please select the class you're most likely to attend, so we can pass your details on to the correct instructor.

Abergavenny – Llanfoist Village Hall, NP7 9LP
Abertillery – Wyndham Vowles Community Centre, NP13 1PJ
Usk – Memorial Hall, NP15 1AD
Tredegar – Fresh Active Gym, NP22 3EJ
Ebbw Vale – All Saints Catholic Church, NP23 6JQ
Blaenavon – The Band Hall, NP4 9NH
Nantyglo – Winchestown OAP Hall, NP23 4BJ
Monmouth – Monmouth Leisure Centre, NP25 3DP

PRIVACY STATEMENT
All information is held in the strictest confidence and can only be accessed by our Instructors and relevant members
of our management team. See our privacy policy for more details. We will use your data to keep a record of your membership and may occasionally contact you about events and opportunities organised by us.

DECLARATION OF CONSENT TO EXERCISE

I confirm that the health and personal information I have given on this form is, to the best of my knowledge, correct.
I understand that taking part in physical activity can carry a risk, and I accept all responsibility for that risk.