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Registration
Saheli Staff
Source of Funding
Select Source of Funding
HI TAWS
NNS Hall Green
NNS Hodge Hill
NNS Yardley
Heart Of England
Date of triage
First Name
Last Name
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Area
Email
Phone
Date Of Birth
Emergency Contact Name
Emergency Contact Number
Gender
Female
Male
Prefer not to say
Other
Disability - physical or mental health conditions or illnesses lasting or expected to last for 12 months or more.
Yes
No
Prefer not to say
Other
Disability or illness description
Occupation
What is your ethnic group?
White
Mixed / Multiple Ethnic groups
Black/African/Caribbean/Black British
Asian/Asian British
Other Ethnic Group
Prefer not to say
GP Name
GP Practice Name
Surgery Address(if known)
Saheli Card number
TAWS Wellbeing Card Number
BCC Leisure Card No (optional)
Pre-activity questions
Doctor advised not to participate in exercise
Yes
No
Pain in chest at rest or when you do physical activity
Yes
No
Lose balance because of dizziness or lose consciousness
Yes
No
Short of breath at rest or doing light activity
Yes
No
Health Condition
Yes
No
Ever had stroke or a mini stroke
Yes
No
Difficulties with breathing e.g. Asthma, other lung condition
Yes
No
Diabetes, high blood pressure or epilepsy
Yes
No
Bone, joint, muscular or neurological condition
Yes
No
Any operations in the last 3 months
Yes
No
Had fall in the last 12 months
Yes
No
Have (or had) cancer
Yes
No
Medication required in an emergency
Yes
No
Further details on above question
180 turn score
Timed up and go score
Forward Reach score
Hamstring Reach score
Height - cms (enter numbers only)
Weight - kg (enter numbers only)
BMI (enter numbers only)
Blood Pressure: Systolic/Diastolic
Heart Rate - BPM (enter numbers only)
Compared to your physical activity over the past three months, was last week’s physical activity more, less or about the same?
Rigorours
Moderate
Sedentary
Quality Sleep [1=Poor, 5=Good]
1
5
Hours of Sleep (Per Day)
Nutrition Habbits [1=Poor, 5=Good]
1
5
Description
Glasses of Water Per Day
Sugary Drinks Habbit [Cans/Drinks]
Description of Sugary Drinks Consumptions (Per Day)
Do You Smoke?
Yes
No
PAR 7 (including walking) score
PAR 7 (excluding walking score)
WEBSWM SCORE
Happiness Pulse - General Wellbeing score
Happiness Pulse - Be score
Happiness Pulse - Do score
Happiness Pulse - Connect score
Aims and goals
To get fit
To improve my health
To meet people
To lose or maintain weight
To improve my confidence
To improve or learn an activity or skill
To help me get a job
To help me become a volunteer
To have fun
GP/health professional referred or advised me
To feel good about myself
Other
Now please describe in your own words, what you would like to get from this, and any timescales.
Activities
1. Learn to ride a bike - D
2. Led Bike ride - D
3. Women only activities - B/D/C
4. Running Group - D
5. Walking for Health Group - D/C
6. Walking/Hiking/Rambling - D/C
7. Learn to Swim - D
8. Lane Swimming - D
9. Aqua Aerobics - D
10. Gym Membership - D
11. Spinning - D
12. Aerobics/Step/Yoga/Pilates - D
13. Stronger Stretched Balanced Class -
14. Chair Based Exercise Class - B/D
15. Tai Chi - B/D/C
16. African/Belly/Bhangra/Salsa Dance - D
17. Social Club – Learn a new skill - D/C
18. Supported Gym based program - D
19. Book Club - D/C
20. Singing for the Brain - B/D
21. Knitting, Crochet, Sewing - D/C
22. Photography - B/D
23. Volunteer - D/C
24. English Speaking role play - D/C
25. Coffee & Chat - C
26. Diabetes UK – Healthier Diet Group - B/D
27. Healthier Diet Group - B/C
28. Carers Activity Group - C
29. Badminton - D
30. Football - D
31. Basketball - D
32. Green Fingers – Allotments - D
33. Martial Arts - D
Other (please specify)
Risk Stratification
LOW
MEDIUM
HIGH
Are You Interested in Weight Management Support?
Yes
No
Are You Interested in Nutrition Support?
Yes
No
Assistance with finance, housing or any other types of support?
Yes
No
Describe Area Where assistance is required
Review of progress date
Applicant consent
Yes
No
Media consent
Yes
No
Please tell us how you heard about Saheli, The Active Wellbeing Society, or this scheme
My GP
Twitter – specify below if known
Facebook – specify below if known
Saheli Website
The Active Wellbeing Society Website
Word of mouth
Further Comments to support any of the above items here
Tracking Your Improvements:
Since Attending Saheli, Has Your Mental Health/Wellbeing Improved?
Yes
No
Since Attending Saheli activities, Would You Say You Feel Less Lonely/Isolated?
Yes
No
Since Attending Saheli activities, Would You Say You Feel Healthier & Fitter?
Yes
No
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