Professional referral form

Pregnancy referral form

LEAF for 0-6 years referral form please note - this form needs to be downloaded to be completed, then saved an emailed to us at . 

Childhood Obesity Pathways:

Care Pathway 0-2 Years

Care Pathway 2-16 Years

Please complete all mandatory fields marked *

Referring Professional's Details

Name *
Job Title *
Organisation *
Email Address *
Telephone Number *
Address *

I would like to refer the following patient for:

Please select relevant programmes *

Healthy Weight 7-13 referral criteria 

Healthy Weight 13-17 referral criteria 

PLEASE NOTE  Children or young people at or above the 98th centile for BMI should first be assessed by their GP in line with NICE and OSCA guidance for overweight children to identify any comorbidities or underlying clinical causes. GP referral for acceptance onto the Healthy Weight 7-13 or 13-17 Programme is required. TEMPLATE GP Referral Letter
Healthy Weight adult referral criteria 

Physical Activity Review referral criteria 
Exclusion Criteria for Exercise 
ContraindicationSigns / Symptoms
New or uncontrolled arrhythmias Palpitations, dizziness, loss of consciousness, irregular beats
Resting or uncontrolled tachycardia Resting heart rate >100 bpm, inappropriate rapid rise in heart rate during exercise that does not stabilise on rest
Uncontrolled hypertension
Resting SBP>180 mmHg or Resting DBP>100 mmHg
Signs and symptoms rare, assessed with BP monitoring
Symptomatic hypotension Light headedness, dizziness/fainting especially when moving from lying or sitting or on cessation of exercise
Unstable angina New angina or change in pattern of established angina
Unstable or acute heart failure Fluid retention (excessive breathlessness, rapid weight gain, swollen ankles, pitting oedema)
Unstable diabetes Medication reviewed/changed recently, repeated hypoglycaemia. Hyperglycaemia: pre-exercise glucose >13 mmol = do not exercise
Febrile illness Fevers, temperature >38°C
Additional contraindications to consider: (use your clinical knowledge and knowledge of patient)
Uncontrolled or poorly controlled asthma or COPD, unstable cancer or blood disorders, osteoporosis/high fracture risk or any unexplained symptoms that could cause risk of injury or exacerbation
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Patient details

Full name *
Parent / guardian (if applicable) 
Address *
Postcode *
Date of Birth *
Contact Telephone *
Email address 
NHS number 
Is the family working with any other social or health agencies? Please specify 
Access and support requirements 
Additional information about disability or special requirements 

Client consent

Consent to all 
Consent to ring 
Consent to leave message 
Consent to text 
Consent to follow up contact *

Consent to GP contact *

Statement of consent for patients:

The information you provide to Healthy Cornwall will be stored securely in accordance with Section 7 of the Data Protection Act 1998 and only accessed and processed by relevant staff. Your information will be used for the purpose of providing a service to you; it would be shared only if there was a legal reason to do so i.e. safeguarding concerns. The information may also be used, once anonymised, for reporting purposes. You have the right to restrict and/or withdraw consent at any time for us to store and process your information. For more information, please refer to our Privacy Notice which can be found on the Healthy Cornwall website which complies with General Data Protection Regulations 2018.

I confirm that the client/representative has read/ been read the above statement and has made clear their wish to consent or not. Consent was given: *
Other method of consent 

Please state to client:

I have made clear that obtainment of personal information is necessary to access our services and we require consent to do so. More information on what we do with this data, their rights to withdraw the data and how long we keep it for can be found on our Privacy Notice which can be found on the Healthy Cornwall website.


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