HYROX for Health Package

Name: HYROX for Health Package
SKU: 353
Price: 200.00 GBP
Availability: InStock

£200.00

HYROX for Health Package quantity

Category: Uncategorized

Description

Description

Name *

First

Last

Email *

Phone Number *

What is your reason for referral? *

Alcohol/drug rehabilitation
Cancer
Cardiovascular disease
Completion of cardiac rehabilitation
Diabetes
Family history of coronary heart disease
Heart failure
Hypertension
Joint, mobility or musculoskeletal problem
Mental health/emotional wellbeing
Neurological condition
Overweight (BMI 25-29.9)
Smoker
High cholesterol

If you ticked yes to any of the above, please add more detail *

If you have a condition not listed above, please provide more detail

Please select those that apply to you *

I am inactive (I do less than 30 minutes of moderate physical activity per week)
I am aged 19 years or over
I am committed to long term lifestyle change
I am a Derbyshire resident
I have one or more of the conditions listed above

Please write any information that could affect your ability to exercise, including past and present medical information. Or, type N/A *

I give consent that I have been given the all clear to take part in a specialised exercise programme by a medical professional (Dr, physio, consultant etc) *

I consent

GP or consultant name

GP or consultant contact number

GP surgery or hospital address

Please tick once you have read all notes below *

The FiiT for Life Programme is for inactive people, those not used to structural physical activity
You must be committed to making a long-term lifestyle change and be ready to start the programme
The scheme is not always free, the cost will vary depending on your medical conditions.
FiiT for Life have the right to decline your engagement on the programme.
This referral form is valid for 1 month from when it is signed by the health professional
If there are changes to your health, please inform a FiiT for Life coach.
I understand that I may need to complete a new form following health changes

I give me consent to participate in the FiiT for Life programme *