Trilogy Weight Loss Programme 1. (Lings Forum & Virtual)

Please note once we have received your supporting information we will be in touch to confirm your place if you meet our eligibility criteria. If your supporting information does not meet our eligibility criteria, we will be in contact with alternative membership options. All applications submitted between 15th December 2021 and 4th January 2022 will be reviewed in January.

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* 1. Your contact details

Name

Address

Address 2

City/Town

Postal Code

Country

Email Address

Phone Number

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* 2. What is your current weight (kgs)

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* 3. What is your current height (cms)

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* 4. Date of Birth

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* 5. Would you like to attend?

In Person Course

Virtual Course

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* 6. How did you join the group?

Other Health Professional

Non Health Professional

Self Referral

Other (please specify)

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* 7. How would you describe your gender?

Male

Female

Indeterminate (unable to be classified as either male or female)

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* 8. How would you describe your ethnicity?

White: British

White: Irish

White: Any other White background

Mixed: White and Black Caribbean

Mixed: White and Black African

Mixed: White and Asian

Mixed: Any other mixed background

Asian or Asian British: Indian

Asian or Asian British: Pakistani

Asian or Asian British: Bangladeshi

Asian or Asian British: Any other Asian background

Black or Black British: Caribbean

Black or Black British: African

Black or Black British: Any other Black background

Other Ethnic Groups: Chinese

Other Ethnic Groups: Any other ethnic group

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* 9. Please state your religious denomination

Baha’i

Buddhist

Christian

Hindu

Jain

Jewish

Muslim

Pagan

Sikh

Zoroastrian

None

Other (please specify)

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* 10. What is your employment status?

Employed

Unemployed and Seeking Work

Students who are undertaking full (at least 16 hours per week) or part-time (less than 16 hours per week) education or training and who are not working or actively seeking work

Long-term sick or disabled, receiving Incapacity Benefit, Income Support or both; or Employment and Support allowance

Homemaker looking after the family or home and who are not working or actively seeking work

Not receiving benefits and who are not working or actively seeking work

Unpaid voluntary work who are not working or actively seeking work

Retired

Prefer not to say

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* 11. How would you describe your sexual orientation?

Heterosexual or Straight

Gay or Lesbian

Bisexual

Other not listed

Do not know

Prefer not to say

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* 12. Are you currently pregnant?

Yes

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* 13. Do you have any disabilities?

Behavioural or Emotional

Hearing

Manual or Dexterity (experiences difficulty performing tasks with their hands.)

Memory or ability to concentrate, learn or understand (Learning Disability)

Mobility and Gross Motor (use of physical aids to move around)

Personal, Self-Care and Continence

Progressive Conditions and Physical Health (long term conditions such as cancer, MS, HIV)

Sight

Speech

No disability

If you have selected an option above, please state the exact nature of your disability

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* 14. Are you listed on the Severe Mental Illness register?

Yes

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* 15. Are you listed on the learning disability register?

Yes

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* 16. Do you have any of these conditions?

Hypertension

Renal disease

Cardiac disease

Mental health disorder

Thromboembolic disorder

Haematological disorder

Central nervous system disorder

Diabetes

Autoimmune disease

Cancer

Infectious Hepatitis A

Serum Hepatitis B

Hepatitis C

Endocrine disorder

Respiratory disease

Gastrointestinal disorder

Musculoskeletal disorder

Gynaecological problems

Eating Disorder

Other

No disability

If you have selected an option above please specify the exact nature of your condition

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* 17. Trilogy Leisure Physical Activity Readiness Questionnaire

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life.

	Yes	No
Has a Doctor / Medical Professional ever diagnosed you with a heart condition and indicated you should restrict your physical activity?	Has a Doctor / Medical Professional ever diagnosed you with a heart condition and indicated you should restrict your physical activity? Yes	Has a Doctor / Medical Professional ever diagnosed you with a heart condition and indicated you should restrict your physical activity? No
When you perform physical activity, do you feel pain in your chest?	When you perform physical activity, do you feel pain in your chest? Yes	When you perform physical activity, do you feel pain in your chest? No
When you were not engaging in physical activity, have you experienced chest pain in the past month?	When you were not engaging in physical activity, have you experienced chest pain in the past month? Yes	When you were not engaging in physical activity, have you experienced chest pain in the past month? No
Do you ever faint or get dizzy and lose your balance?	Do you ever faint or get dizzy and lose your balance? Yes	Do you ever faint or get dizzy and lose your balance? No
Do you have an injury or orthopaedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity?	Do you have an injury or orthopaedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity? Yes	Do you have an injury or orthopaedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity? No
Do you have high blood pressure or a heart condition in which a Doctor / Medical Professional is currently prescribing a medication?	Do you have high blood pressure or a heart condition in which a Doctor / Medical Professional is currently prescribing a medication? Yes	Do you have high blood pressure or a heart condition in which a Doctor / Medical Professional is currently prescribing a medication? No
Are you 69 years of age or older and not used to being very active?	Are you 69 years of age or older and not used to being very active? Yes	Are you 69 years of age or older and not used to being very active? No
Do you know of any other reason you should not exercise or increase your physical activity?	Do you know of any other reason you should not exercise or increase your physical activity? Yes	Do you know of any other reason you should not exercise or increase your physical activity? No
I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in physical exercise and duly undertake the activity at my own risk. Any liability on the part of the operators is excluded unless negligence can be proven. I agree to observe the rules and conditions of membership. I also acknowledge that I must not use any piece of equipment for which I have not been shown how to use by an instructor. I confirm that the information that I have provided is correct at this time and should I become aware of any relevant changes to my health or condition, I will inform an instructor.	I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in physical exercise and duly undertake the activity at my own risk. Any liability on the part of the operators is excluded unless negligence can be proven. I agree to observe the rules and conditions of membership. I also acknowledge that I must not use any piece of equipment for which I have not been shown how to use by an instructor. I confirm that the information that I have provided is correct at this time and should I become aware of any relevant changes to my health or condition, I will inform an instructor. Yes	I have read, understood and completed the above questionnaire and acknowledge that there are risks and dangers inherent in physical exercise and duly undertake the activity at my own risk. Any liability on the part of the operators is excluded unless negligence can be proven. I agree to observe the rules and conditions of membership. I also acknowledge that I must not use any piece of equipment for which I have not been shown how to use by an instructor. I confirm that the information that I have provided is correct at this time and should I become aware of any relevant changes to my health or condition, I will inform an instructor. No