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Live Well Newham
Live Well Newham self-referral
Live Well Newham self-referral
Who are you referring?
*
I am referring myself
I am referring someone else
Please answer the following questions with the details of the person you are submitting the referral for.
Please select one:
*
I live in Newham
I work for Newham Council
Please confirm your work email address
*
Confirm the individual understands that: their personal and medical information is being shared with Xyla Health & Wellbeing so they can participate in the programme, outcome data will be shared securely with their GP, their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act).
Untitled
*
Yes, I confirm the individual understands the above.
Untitled
*
I confirm that the referee has given verbal consent to be referred
What is the name of your GP/Healthcare provider?
Which organisation are you referring from/what is your relation to the referee?
*
Please fill the below information for the person you are referring
First name
*
Last name
*
Email
*
Phone
*
Address (please note you must be a Newham resident to be eligible for this programme)
Street address
*
Address line 2
City
*
County
*
Postcode
*
Date of birth* (must be over 18 years of age)
Day
*
Month
*
Year
*
Sex
*
Male
Female
Prefer not to say
Hidden
What is your ethnic group?
*
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Any other Asian background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: Any other mixed background
White: British or Mixed British
White: Irish
White: Any other white background
Other Ethnic Groups: Chinese
Any Other Ethnic Group
Not Known
Prefer not to say
What is your ethnic group?
*
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Any other Asian background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: Any other mixed background
White: British or Mixed British
White: Irish
White: Any other white background
Other Ethnic Groups: Chinese
Any Other Ethnic Group
Not Known
Prefer not to say
BMI
If you don't know your height or weight, please tell us your waist circumference in centimeters instead
If you don't know your height or weight, please tell us your waist circumference in centimeters instead
Your BMI is less than 25, meaning you are within the healthy range and are ineligible for this programme.
Your BMI is less than 23, meaning you are within the healthy range and are ineligible for this programme.
Your waist circumference is less than 90cm, meaning you are within the healthy range and are ineligible for this programme.
Your waist circumference is less than 94cm, meaning you are within the healthy range and are ineligible for this programme.
Your waist circumference is less than 80cm, meaning you are within the healthy range and are ineligible for this programme.
Have you been pregnant in the last three years?
*
Yes
No
Not stated
Are you currently on the National Diabetes Prevention Programme (NDPP) or Low Calorie Diet programme ?
*
Yes
No
As you are already participating in the NHS Diabetes Prevention Programme or NHS Low Calorie Diet, you are ineligible for the programme.
Are you currently pregnant?
*
Yes
No
As you are pregnant, you are ineligible for the programme, please speak to your healthcare professional for more advice.
Do you have an underlying medical cause for obesity?
*
Yes
No
As you have an underlying medical cause for obesity, you are ineligible for the programme, please speak to your healthcare professional for more advice.
Have you already accessed a Tier 2 weight management service twice in the last year?
*
Yes
No
As you have already accessed a Tier 2 weight management service twice in the last year, you are ineligible for the programme, please speak to your healthcare professional for more advice.
How did you hear about us?
*
Friend/Family
Google
Email
My GP/Healthcare provider
Social media
Workplace
Community information table
Health information booklet
Community outreach
Other
Consent 1
*
I declare this information is true and correct; if not then I am aware that I could be putting myself at risk by joining this programme.
Consent 2
*
I agree to the
terms and conditions
CAPTCHA
Who are you referring?
*
I am referring myself
I am referring someone else
Please answer the following questions with the details of the person you are submitting the referral for.
Please select one:
*
I live in Newham
I work for Newham Council
Please confirm your work email address
*
Confirm the individual understands that: their personal and medical information is being shared with Xyla Health & Wellbeing so they can participate in the programme, outcome data will be shared securely with their GP, their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act).
Untitled
*
Yes, I confirm the individual understands the above.
Untitled
*
I confirm that the referee has given verbal consent to be referred
What is the name of your GP/Healthcare provider?
Which organisation are you referring from/what is your relation to the referee?
*
Please fill the below information for the person you are referring
First name
*
Last name
*
Email
*
Phone
*
Address (please note you must be a Newham resident to be eligible for this programme)
Street address
*
Address line 2
City
*
County
*
Postcode
*
Date of birth* (must be over 18 years of age)
Day
*
Month
*
Year
*
Sex
*
Male
Female
Prefer not to say
Hidden
What is your ethnic group?
*
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Any other Asian background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: Any other mixed background
White: British or Mixed British
White: Irish
White: Any other white background
Other Ethnic Groups: Chinese
Any Other Ethnic Group
Not Known
Prefer not to say
What is your ethnic group?
*
Asian or Asian British: Bangladeshi
Asian or Asian British: Indian
Asian or Asian British: Pakistani
Asian or Asian British: Any other Asian background
Black or Black British: African
Black or Black British: Caribbean
Black or Black British: Any other Black background
Mixed: White and Asian
Mixed: White and Black African
Mixed: White and Black Caribbean
Mixed: Any other mixed background
White: British or Mixed British
White: Irish
White: Any other white background
Other Ethnic Groups: Chinese
Any Other Ethnic Group
Not Known
Prefer not to say
BMI
If you don't know your height or weight, please tell us your waist circumference in centimeters instead
If you don't know your height or weight, please tell us your waist circumference in centimeters instead
Your BMI is less than 25, meaning you are within the healthy range and are ineligible for this programme.
Your BMI is less than 23, meaning you are within the healthy range and are ineligible for this programme.
Your waist circumference is less than 90cm, meaning you are within the healthy range and are ineligible for this programme.
Your waist circumference is less than 94cm, meaning you are within the healthy range and are ineligible for this programme.
Your waist circumference is less than 80cm, meaning you are within the healthy range and are ineligible for this programme.
Have you been pregnant in the last three years?
*
Yes
No
Not stated
Are you currently on the National Diabetes Prevention Programme (NDPP) or Low Calorie Diet programme ?
*
Yes
No
As you are already participating in the NHS Diabetes Prevention Programme or NHS Low Calorie Diet, you are ineligible for the programme.
Are you currently pregnant?
*
Yes
No
As you are pregnant, you are ineligible for the programme, please speak to your healthcare professional for more advice.
Do you have an underlying medical cause for obesity?
*
Yes
No
As you have an underlying medical cause for obesity, you are ineligible for the programme, please speak to your healthcare professional for more advice.
Have you already accessed a Tier 2 weight management service twice in the last year?
*
Yes
No
As you have already accessed a Tier 2 weight management service twice in the last year, you are ineligible for the programme, please speak to your healthcare professional for more advice.
How did you hear about us?
*
Friend/Family
Google
Email
My GP/Healthcare provider
Social media
Workplace
Community information table
Health information booklet
Community outreach
Other
Consent 1
*
I declare this information is true and correct; if not then I am aware that I could be putting myself at risk by joining this programme.
Consent 2
*
I agree to the
terms and conditions
CAPTCHA
