Hillbrow Health and Wellbeing (WAH) Self-Referral Form

Hillbrow Health & Wellbeing Self Referral Form

Complete the fields below
Your Details
Full Name*

TitleFirst NameLast Name
Date of birth*

DayMonthYear
Date
Contact Number*
Please enter a valid phone number.Format: 00000 000000.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

TownCounty

Post Code
Your GP Surgery:*
Preferred Contact Method: *

Your Health

This helps us tailor your assessment (please tick all that apply)
Asthma (controlled)Clinically overweight (BMI >30)Chronic fatigue / Long CovidHeart disease risk factors (e.g., smoking,hyperlipidemia)COPD (emphysema/chronic bronchitis)Hypertension (mild–moderate / onbeta-blockers)Deconditioning (age/inactivity)Depression (mild–moderate) / post-natalMultipleSclerosisOsteoarthritisOsteoporosis (no pathological fractures)Parkinson’sPre/Post‑op knee/hip/general surgery (not cardiac)Rheumatoid arthritisStress/ AnxietyType1 Diabetes (insulin‑dependent)Type2 Diabetes (diet/tablet controlled)Other
Current Medication
Please detail your current medications:
NoYes
If yes, please provide details.
Goals
What would you like to achieve?
Appointment Request
Preferred days/times for assessment (please provide 2–3 options):
Safety Check (please read)

If you have any of the following unstable or uncontrolled conditions, please speak to your GP before self‑referring:

Recent serious illness or operation; unstable heart disease/arrhythmia; severe uncontrolled blood pressure (>180/100); uncontrolled asthma or diabetes; rapidly worsening or terminal illness; episodes of unexplained fainting.

If unsure, email referral@waveactive.org for guidance.
Hillbrow Health and Wellbeing Centre – Participant Information

At Hillbrow Health & Wellbeing, we are dedicated to supporting your wellbeing through safe, enjoyable physical activity in a safe environment, with qualified first aiders on site.

Our Health Improvement Practitioners are qualified specialist Fitness Instructors who support various health conditions through physical activity. However, they are not medically trained and cannot offer medical advice or clinical assessment.

Because of this, you are fully responsible for ensuring that you have sought appropriate medical advice before joining any of our classes. This is especially important if you have a chronic health condition, are recovering from illness or surgery, or are considering taking part in rehabilitation-based activities.

If you have any uncertainty about your ability to exercise safely, you must consult a qualified healthcare professional beforehand.

Our sessions are designed to be flexible so you can work at a pace that feels comfortable for you. As your activity level increases, you may experience heavier breathing, a faster heart rate, or mild strain on your muscles and joints—these are normal responses to exercise. Reintroducing physical activity gradually is the safest approach.

Some specialist classes, such as our heart and lung programmes, require an initial assessment with one of our Health Improvement Practitioners before you begin.

This is assessment if free of charge. A member of our team will contact you within 5 working days to arrange this.

Your health and safety remain your personal responsibility. We encourage you to keep our team updated about any changes to your health so we can continue to support you appropriately within the scope of our service.

Please email referral@waveactive.org or call 01323 408857 if you have any questions.
Via GP or other clinician at South Downs Health and Care (SDHC)Social MediaFriend/ FamilySouth Downs Health Care Website ( SDHC)Hillbrow Health and Wellbeing StaffOther
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Hillbrow Health & Wellbeing Self Referral Form

Your Details

Your Health

Current Medication

Goals

Appointment Request