The Service

Eating a healthy, balanced diet provides nutrients to your body. These nutrients give you energy and keep your heart beating, your brain active, and your muscles working.

Self Referral Form

If you would like to join one of our Eat 4 Health programme options please complete the form below and a member of our team will contact you to discuss the options available in your area, answer any questions and get you booked on.

The Eat 4 Health weight management service is only available to people aged over 16 with a BMI ≥ 25kg.m² living or registered with a GP surgery in West Berkshire, Reading and Slough. If you have any queries please click here to contact the E4H team.

Title

Forename(s) *

Surname *

Date of Birth *
- -

GP Surgery

GP Name

Ethnicity

Sex

Postcode
Find

Phone *

Mobile

Email

Preferred Language

To assess your suitability for the programme please provide us with the following information:

Weight (stones & pounds) or (kilograms)

Height (feet & inches) or (metres)

Please indicate your preferred location(s)



Do you smoke?

If you are interested in quitting smoking, would you like the local NHS Stop Smoking Service to contact you?

Answer Yes or No to the following questions:

Has your doctor ever said that you have a bone or joint problems?

Has your Doctor ever said you have or have had a heart problem?

Have you ever been diagnosed with epilepsy?

Have you ever been diagnosed with high blood pressure?

Have you ever been diagnosed with diabetes?

Do you suffer from Asthma?

Have you ever been diagnosed with a dietary illness?

Have you ever felt pain in your chest at rest or when you do physical exercise?

Are you currently taking any medication?

In the past year have you had any major illness or surgery?

Do you ever lose your balance because of dizziness or lose consciousness?

Are you pregnant?

Do you know of any other reason why you should not participate in a physical activity programme?

Solutions4health would encourage you to provide your consent in order that we can process data and information about you. We will share this data where necessary with other health professionals such as your GP or specialist services. The information we collect and process will be used to help us meet the contractual obligations as set down by the local health service commissioners in accordance with the service we are providing. You can request to view, amend or delete your data at any time by contacting us at (www.solutions4health.co.uk/contact).