ExWell Referral FormC:\Users\lorraine\Desktop\noel\LOGO.png

The ExWell Medical team will contact the patient to arrange an induction/assessment session

Patient Details

Name:

Tel

DOB

Address

Next of Kin Name

Next of Kin Tel

Referrer Details:

Referrer Name & Occupation

Hospital / Clinic

Contacts

Tel:

Email

Patient GP Name

Patient GP Address

Medical Details:

Main Diagnosis

Co-Morbidities

Medications

Comments

SIGNED:                                        DATE:        

Absolute contraindications to exercise

A recent significant change in the resting ECG suggesting significant ischaemia, recent myocardial infarction (within 2 days) or other acute cardiac event

Unstable angina

Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic  compromise

Symptomatic severe aortic stenosis

Uncontrolled symptomatic heart failure

Acute pulmonary embolus or pulmonary infarction

Acute myocarditis or pericarditis

Suspected or known dissecting aneurysm

Acute systematic infection, accompanied by fever, body aches, or  swollen lymph glands  

American College of Sports Medicine. ACSM’s Guidelines for Exercise testing and Prescription, 9th edition. Lippincott Williams & Wilkins, Philadelphia, 2013.

For more information please contact info@exwell.ie or visit www.exwell.ie