Eat, Move, Be Happy Enrolment
If you are interested in enrolling in any of our programmes, just fill out the form below to sign up.
* Required
Email address
*
Your email
First name
*
Your answer
Last name
*
Your answer
Contact number
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Funding options
*
Which GP practice is funding you. If you have not had CONFIRMATION of funding from your GP, choose "Self Funded".
Choose
Self Funded
Addingham Medical Centre
Dyneley House Surgery
Grange Park Surgery
IG Medical (Ilkley Moor & Grassington)
Ilkley & Wharfedale Medical Practice
Ling House Medical Centre
North Street Surgery
Townhead Surgery & Branch
Which service are you interested in?
*
For full descriptions of all the services on offer, go to
www.EatMoveBeHappy.com
Choose
The First Step - 3 week lifestyle change programme
Live Better - 12 week health coaching programme
Move Better - weekly online exercise class
The First Steps & Live Better bundle
Live Better & Move Better bundle
The First Steps, Live Better & Move Better bundle
Preferred start date
*
From when can you start? We cannot promise this date, but we will do our best to accommodate.
MM
/
DD
/
YYYY
Medical conditions or disabilities
Please tick if you have any of the following:
High blood pressure
Cardiovascular disease
Diabetes
High cholesterol
Excess body weight (BMI 30+)
Sensory impairment
Mental health condition
Physical disability
Learning disability
Other:
What do you want to achieve from completing this programme?
*
Your answer
How confident are you at achieving this goal?
*
Not confident
1
2
3
4
5
6
Very confident
How confident are you at managing your weight?
*
Not confident
1
2
3
4
5
6
Very confident
How confident are you at managing your health and wellbeing?
*
Not confident
1
2
3
4
5
6
Very confident
How confident are you at managing your exercise and activity?
*
Not confident
1
2
3
4
5
6
Very confident
Where did you hear about this programme?
*
Your answer
Disclaimer
*
I acknowledge I take part in this programme under my own free will and accept full responsibility. The contents of this programme are for information purposes only and are not a substitute for professional medical advice.
I agree
Required
Send me a copy of my responses.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms