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Cornwall Healthy Weight Referral form

Pregnancy Referral Form

Click here to download the referral form

LEAF for 0-6 years Referral Form

Click here to download the referral form

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 to Cornwall Healthy Weight

Please tick relevant programmes 





Healthy Weight 7-13 referral criteria 
BMI 


Healthy Weight 13-17 referral criteria 
BMI 


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 
BMI 



PLEASE NOTE  Adults with a BMI between 35-39.9 should first be assessed by their GP in line with NICE clinical guidance 189 (Additional Information: Obesity: identification, assessment and management) to identify any comorbidities or underlying clinical causes. GP referral for acceptance onto the Healthy Weight Adult Programme is required. Please download this TEMPLATE GP Referral Letter and ask your client to speak to their GP.
PLEASE NOTE  Adults with a BMI 40 or more should first be assessed by their GP in line with NICE clinical guidance 189 (Additional Information: Obesity: identification, assessment and management) to identify any comorbidities or underlying clinical causes. GP referral for acceptance onto the Healthy Weight Adult Programme is required. Please download this TEMPLATE GP Referral Letter and ask your client to speak to their GP.
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

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:

I agree that the information I provide Healthy Cornwall will be stored securely and only seen by staff members dealing with my referral. To ensure I receive the highest quality of service my information will be shared with relevant health and social care professionals. Only for legal reasons will my personal information be shared with others i.e. safeguarding concerns.

I understand that this information will be used for the purpose of providing a service. I also understand that anonymised information gained from these services may be used for statistical purposes.

I understand that I may withdraw consent to share information at any time, this may restrict or prevent a service being able to be offered to me.

I understand that I have the right to restrict what information may be shared and with whom, but this may affect the provision of services to me.

I understand that my information will be held securely on paper and/or on a computer in accordance with the Data Protection Act 1998.

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.