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Give us a call via the Health Promotion Service on 01209 313419 01209 313419

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

I confirm the client has consented to retention of personal information which will be retained for a period of 18 months once support has been completed. *