Bridgwater Health and Wellbeing Coaches - Self-Referral Section Bridgwater Health and Wellbeing Coaches - Self-Referral Hello and welcome, from the Health and Wellbeing Coaches!Your Health and Wellbeing Coaches support individuals with long term health conditions to live fulfilling, active lives. We can help you access fun, safe activities and guide you as you overcome your challenges. We can point you towards community groups allowing you to build friendships while starting to move more. So that we can better understand how to support you, could you please complete the following questions. Name*: Date of birth*: - 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st - January February March April May June July August September October November December - 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 Gender: - Choose - Male Female Transgender Male Transgender Female Prefer not to say Other Other Email: Phone number*: Doctor's surgery - Bridgwater*: - Choose - Cranleigh Gardens Redgate Somerset Bridge Taunton Road East Quay Polden Medical Practice Cannington Health Centre North Petherton Surgery Quantock Medical Centre Victoria Park Medical Centre Postcode*: Do you have any of the health conditions listed below?* Yes No - Unstable and uncontrolled angina or heart disease.- Pain in limbs when exercising with heart disease.- A stroke or TIA less than 3 months ago.- Osteoporosis with a history of fractures.- Blood pressure that drops when standing.- COPD with ventilator support- Severe arthritis with nerve damage- Advanced diabetes How much time in an average week do you spend moving in ways that leave you feeling slightly warm and out of breath? Less than half-an-hour 1/2 to 1 1/2 hours 1 1/2 to 2 1/2 hours more than 2 1/2 hours How much time do you spend moving outdoors on an average week? Less than half-an-hour 1/2 to 1 1/2 hours 1 1/2 to 2 1/2 hours more than 2 1/2 hours How confident are you that you can access appropriate activities to improve your health and wellbeing? ["activities" could be any kind of social group, crafts, library, physical activity, out in the community or at home]: 1 - Not at all confident2.3.4.5678910- Extremely confident 1 - Not at all confident 2. 3. 4. 650537 650538 650539 650540 650541 10- Extremely confident How would you rate your ability (knowledge, skills and confidence) managing your own health and wellbeing? 1. Not able2. A little able3. Quite able4. Very able 1. Not able 2. A little able 3. Quite able 4. Very able Have you visited your doctor to discuss low mood, depression or anxiety issues in the last 12 months? Yes No Our service works directly with your GP practice, this means that we will share information with the practice to let them know we are working together. We have access to your notes in the surgery, and will update your notes with necessary information after an appointment. Please confirm that you understand and agree to this.* Yes How would you prefer to have your coach appointments? We will do our best to accommodate you within our availability. In person - at the GP surgery In-person - at the Victoria Park Health and Wellbeing Hub Online via Teams call By telephone Do you have any access needs that we should take into account? Where did you hear about our service? GDPR:SASP's legal obligation is to retain information of our customers through this form for the sole purpose of providing information and continued exercise provision through any of our provided services. Upon completion of your form through website, all electronic files/records and information therein may be stored for as long as the patient remains in the care of the Health and Wellbeing Coaching team; and thereafter for a period of up to 5 years of inactivity, under our statutory requirement. Information will be held electronically in files accessible only by SASP staff, who are directly involved in patient care or data entry processing of patient records. All information provided will be treated as confidential and will not be given to any other person(s)/organisations(s) without written consent of the patient concerned. Please also note that it is your right to withdraw your consent/opt out at any time. You have a right to request a copy of the personal data that SASP holds about you at any time. If you wish to do so, please email enquiries@sasp.co.uk. For further information about what data we collect, why it is collected and what we do with it, please see our full privacy policy at www.sasp.co.uk/privacy-policy
