Melton Sport and Health Alliance

* Required Field

We understand that how you feel can change from day to day. And sometimes, that can make moving more feel like a challenge. It may be that being active has seemed like a big commitment or something that didn’t feel like it was for you. That’s perfectly okay. The truth is that you can start small, and you do not have to get moving when you don’t feel up to it. Ultimately, being active is about finding what works for you. If you'd like to receive personalised support to move more, you are in the right place. Please complete the form below and a member of the Healthy and Active Communities Team will be in touch. **Please note, most services including Leisure Centre activities are not free of charge**

Name*:

Phone number*:

What is your full postcode?*

We will only use this information to understand the areas where people live, to help plan where future provision would be most beneficial. It will not identify your house.

Email address:

Preferred method of contact*:

Phone Email

How did you hear about us?*

Text message from my Doctor/GP Text message from a Physiotherapist at my GP Surgery Text message from my Social Prescriber/Health and Wellbeing Coach Text message from my Pharmacist Text message from a Physiotherapist at my hospital Information leaflet from my Doctor/GP Information leaflet from a Physiotherapist at my GP Surgery Information leaflet from my Social Prescriber/Health and Wellbeing Coach Information leaflet from a Physiotherapist at my hospital Google Word of mouth Newsletter Email Other:

If you were encouraged to contact us by your Doctor, Physiotherapist, Social Prescriber, Pharmacist or anyone else in a healthcare setting, please write their name below:

Additional Information

What best describes your gender?*

Male Female Prefer to self-describe Prefer not to say

What is your date of birth? (dd/mm/yyyy)*:

Which one of the following best describes your ethnic group or background?*

Please tick one option.

White British Mixed or Multiple ethnic groups Asian or Asian British Black Black British Caribbean or African Other ethnic group Prefer not to say

Do you have any physical or mental health conditions or illnesses that have lasted or are expected to last 12 months or more?*

Please tick all that apply.

Yes – mental condition or illness Yes – physical conditional or illness Yes – Other No Prefer not to say

How can we help you to move more today?*

I’d like to get active and meet new people I’d like to know what physical activity opportunities are available in my area I’d like some help to remain active at home I'd like to reduce my risk of falling I’d like some advice about how I can stay motivated to be active I’d like to understand what and how much physical activity is beneficial to my health I'd like specialist support becoming physically with a long term health condition I’d like more information about a particular programme/scheme Other (Please state) Other:

Your health

Have you ever been diagnosed with any of the following long term health conditions?*

Please tick all that apply.

Asthma Coronary heart disease/Angina Diabetes Type 1 Diabetes Type 2 Chronic Obstructive Pulmonary Disorder (COPD) High cholesterol High blood pressure Joint replacement Obesity (BMI 30+) Osteoarthritis Osteopenia/osteoporosis Rheumatoid arthritis Simple mechanical back pain Stress anxiety depression Other (Please state) Other:

Please provide any readings in relation to the above question:

e.g latest blood pressure reading, type of joint replacement, weight or areas affected by osteoarthritis.

Physical Activity Levels

In the past week, how many minutes of physical activity have you done in total, which was enough to raise your breathing rate?*

Please include sport, fitness and recreation activities, and brisk walking or cycling for any purpose, but do not include physical activity that is part of your work.

Less than 30 minutes (less than half an hour) 30-59 minutes (between half an hour and up to an hour 60-89 minutes (between an hour and up to 1.5 hours) 90-119 minutes (between 1.5 hours and up to 2 hours) 120-149 minutes (between 2 hours and up to 2.5 hours) 150 minutes or more (2.5 hours or more)

In the past week, on how many days have you done exercises that strengthen your muscles?*

This refers to exercises that made your muscles feel some tension, shake or feel warm and includes activities such as lifting weights, sit-ups, yoga, carrying heavy bags or digging the garden.

0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

Melton Borough Council GDPR Statement

We are committed to maintaining the privacy, security, trust and confidence of all our partners, clients and customers when you use our services. Our Privacy Notice explains how we use information about you and how we protect your privacy. www.melton.gov.uk/your-council/data-security-and-access/data-protection/

Consent to share my data*:

I have read and understand the above data sharing agreement, and I consent to providing this information

Yes

Active Together GDPR Statement

Active Together take your privacy seriously and we, along with Melton Borough Council will only use your personal information where necessary to administer your attendance to sport and physical activity programmes in your Locality. We will collect and process data in line with the Data Protection Act 2018. For more information please view our Privacy Policy at www.active-together.org/privacypolicy

Consent to share my data*:

I have read and understand the above data sharing agreement, and I consent to providing this information

Yes

Reset

Contact Us