Gender
Doctor's surgery - Bridgwater*
Do you have any of the health conditions listed below?
Unstable and uncontrolled angina or heart disease.*
Pain in limbs when exercising with heart disease.*
A stroke or TIA less than 3 months ago.*
Osteoporosis with a history of fractures.*
Blood pressure that drops when standing.*
COPD with ventilator support*
Severe arthritis with nerve damage*
Advanced diabetes*
How much time in an average week do you spend moving in ways that leave you feeling slightly warm and out of breath?*
How much time do you spend moving outdoors on an average week?*
How confident are you that you can access appropriate activities to improve your health and wellbeing? ["activities" could be any kind of social group, crafts, library, physical activity, out in the community or at home]:*
How would you rate your ability (knowledge, skills and confidence) managing your own health and wellbeing?*
Have you visited your doctor to discuss low mood, depression or anxiety issues in the last 12 months?*
Our service works directly with your GP practice, this means that we will share information with the practice to let them know we are working together. We have access to your notes in the surgery, and will update your notes with necessary information
Please confirm that you understand and agree to this.*
How would you prefer to have your coach appointments? We will do our best to accommodate you within our availability.*
Do you have any access needs that we should take into account?
Where did you hear about our service?
Security Check*
Add 3 and 6.