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Healthy Lifestyles Referral Form

	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"
	Q1. Would you like support to Get Active? (If no, skip get active question and go to Q2) *	Yes No
	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 No
	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 No
	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 No Don't Know
	Q4. Would you like support with Liver Health? (If no, skip liver health question and go to next section) *	Yes No
	Have you been diagnosed with Non-Alcoholic Fatty Liver Disease (NAFLD)	Yes No 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 No
	Firstname *
	Lastname *
	DOB *
	Address *
	Letter allowed? *	Yes No
	Postcode *
	Email
	Email allowed	Yes No
	Tel
	Mobile *
	SMS allowed? *	Yes No
	Gender *
	Ethnicity *
	Is client religious *	Yes No
	If yes, what religion *
	Sexual Orientation *
	Employment Status *
	Disability Type *
	On Severe Mental Illness Register *	Yes No Not known/ not recorded
	On Learning Disabilities Register *	Yes No 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 No
	GP registered *	Unregistered Registered
	GP Details *
	Interpreter support needed *	Yes No
	If yes, what language *
	How did you hear about the healthy lifestyles support? *