DCRS Interface - DCRSInterface

This Referral Form is for Professionals ONLY.

Use this form to refer a North Somerset patient or resident you are supporting for Healthy Lifestyles support. Please ensure the patient/resident provides consent for us to make contact by email or telephone as provided below.

Eligibility Criteria

To be eligible for healthy lifestyles support to get active, eat well, lose weight and improve liver health, individuals should be 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

Individuals that would like support to Lose weight 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: BMI can be calculated at NHS BMI Calculator

Get Active

Individuals that would like support to Get Active must be:

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

Eat Well

Individuals that would like support to Eat Well:

Will have a diet that does not meet the Eat Well guide recommendations

Liver Health

Individuals that would like support with Liver Health:

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

Details of the patient / resident you are referring:

Consent to record information *

Yes

Firstname *

Lastname *

Is this adult resident in North Somerset? *

Yes

DOB *

Email allowed

Yes

Mobile *

SMS allowed? *

Yes

What service or services are required? *

Anything else we should know?

Details of Referrer

Referrer Name *

Please let us know if you would like to be added to our database to receive information by email (using the address you have provided) from Better Health North Somerset *

Yes

Referrer Email Address *

Referrer Phone Number

Organisation you work for *

If organisation not listed above, please provide organisation name

What is your role? *

Other health care professional

Non-health care professional

There has previously been some concern that long-term conditions could be made worse by physical activity. However, the evidence is that physical activity has an important role to play in preventing and treating many conditions and that, for most people with long-term conditions, the benefits outweigh the risks. This expert consensus, supported by the Office for Health Improvement and Disparities, will help healthcare professionals to have informed, personal conversations with their patients living with long-term conditions. (Moving Medicine Risk Consensus)

If health care / medical professional: do you sign off this person as safe to undertake increased Physical Activity? *

Yes

I am not a medical professional

Decline to sign off – client will undertake PAR-Q+

Practitioner Referral Form