Referral : Welcome

Use this form to self refer yourself for Healthy Lifestyles support.

Eligibility Criteria

You are eligible for healthy lifestyles support to get active, eat well, lose weight and improve liver health if you are aged 18 or more, live in North Somerset and meet at least one of our topic based criteria as listed below:

Topic Specific Criteria
Lose Weight

If you would like support to Lose weight you will meet one of the BMI requirements:

BMI of 25 or more in adults of Caucasian (White European) origin
BMI of 23 or more in adults of Black African, African-Caribbean and Asian origin
BMI of 23 or more in adults living with a co-morbidity / long term health condition

Note: you can calculate your BMI at NHS BMI Calculator

Get Active

If you would like support to Get Active you must be:

Inactive, participating in less than 30 minutes of physical activity per week

Eat Well

If you would like support to Eat Well your:

Diet does not meet the Eat Well guide recommendations

Liver Health

If you would like support with your Liver Health:

You have been diagnosed with Non-Alcoholic Fatty Liver Disease (NAFLD) "Fatty Liver"

If you are requesting support for Get Active, Eat Well, Lose Weight or Liver Health (i.e. Q1 = Yes, Q2 = Yes, Q3 = Yes or Q4 = Yes) it is mandatory to record in the boxes below: your current physical activity levels, if you eat a healthy balanced diet, your weight and height, if you have been diagnosed with Non-Alcoholic Fatty Liver Disease (NAFLD). We cannot process your request without this.

Q1. Would you like support to Get Active? (If no, skip get active question and go to Q2) *

Yes

In the past week, how many minutes of physical activity have you done in total, which was enough to raise your breathing rate? Include sport, fitness and recreation activities, brisk walking or cycling for any purpose, gardening, but do not include physical activity that is part of your work.

0 - 29 minutes

30 - 59 minutes

60 - 89 minutes

120 - 149 minutes

150+ minutes

Q2. Would you like support to Lose Weight? (If no, skip lose weight question and go to Q3) *

Yes

Please enter your Weight (with units, e.g., kg, lbs)?

Please enter your Height (with units, e.g., cm, m)?

Q3. Would you like support to Eat Well? (If no, skip eat well question and go to Q4) *

Yes

Eat Well Guide: A brief summary of the guide is: eat at least 5 portions of a variety of fruit and vegetables a day, base meals on potatoes, bread, rice, pasta or other starchy carbohydrates, eat some beans, pulses, fish, eggs, meat and other protein foods, have some dairy or dairy alternatives (such as soya drinks and yoghurts), choose unsaturated oils and spreads, and eat in small amounts, eat foods high in fat, salt and sugar less often and in small amounts, drink plenty of fluids - the government recommends 6 to 8 cups or glasses a day.

Do you eat a healthy balanced as described in the Eat Well Guide?

Yes

Don't Know

Q4. Would you like support with Liver Health? (If no, skip liver health question and go to next section) *

Yes

Have you been diagnosed with Non-Alcoholic Fatty Liver Disease (NAFLD)

Yes

Don't Know

Please enter your FibroScan / Cap score (above = 275 fatty liver)

Please enter your liver stiffness result (a moderate or severe liver stiffness result is between 7.5-14)

Registration Form Questions

Please note if you complete and submit this section you will be contacted by a healthy lifestyles advisor within two weeks to confirm if you are eligible for 1-1 or group support. If you are not eligible you will be signposted to alternative local support. The healthy lifestyles advisor team can be contacted via email: healthy.lifestyles@n-somerset.gov.uk or telephone: 01934 427661. Please note that when you receive a telephone call from us the number will display as 01934 880000.

Consent to record information *

Yes

Firstname *

Lastname *

DOB *

Address *

Letter allowed? *

Yes

Postcode *

Email allowed

Yes

Tel

Mobile *

SMS allowed? *

Yes

Gender *

Ethnicity *

Is client religious *

Yes

If yes, what religion *

Sexual Orientation *

Employment Status *

Disability Type *

On Severe Mental Illness Register *

Yes

Not known/ not recorded

On Learning Disabilities Register *

Yes

Not known/ not recorded

Please note to be eligible for support any co-morbidities must be stable / controlled.

Comorbidities *

In recovery for *

Asylum Seeker? *

Yes

Is Pregnant

Yes

Have you given birth in the last year?

Yes

GP registered *

Unregistered

Registered

GP Details *

Interpreter support needed *

Yes

If yes, what language *

How did you hear about the healthy lifestyles support? *

Healthy Lifestyles Referral Form