Healthy Lifestyles Referral Form

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

Q2. Would you like support to Lose Weight? (If no, skip lose weight question and go to Q3) *    
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) *    
Do you eat a healthy balanced as described in the Eat Well Guide?

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

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

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)
Consent to record information *    
Firstname *
Lastname *
Address *
Letter allowed? *    
Postcode *
Email allowed    
Mobile *
SMS allowed? *    
Gender *
Ethnicity *
Is client religious *    
If yes, what religion *
Sexual Orientation *
Employment Status *
Disability Type *
On Severe Mental Illness Register *

On Learning Disabilities Register *

Please note to be eligible for support any co-morbidities must be stable / controlled.
Comorbidities *
In recovery for  *
Asylum Seeker? *    
GP registered *    
Interpreter support needed *    
If yes, what language *
How did you hear about the healthy lifestyles support? *