Please complete all required fields!
Thank you for your request to join the Health, Lifestyle, Action Programme.
Please ensure all required fields are completed before submitting the form.
Gender Variant/ Non- Conforming
Not Listed - please specify below
Prefer Not to Answer
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Asian or Asian British
Any other Asian background
Black or Black British
Any other Black background
Other Ethnic Groups
Any other ethnic group – please specify below
North - Eastcote Health Centre
Central - Civic Centre Uxbridge
South - The High Street Practice
Online Via Zoom
Type 1 Diabetes Melitus
Type 2 Diabetes Melitus
Other- please specify below
I confirm that I am 16 years old or over, with the ability to exercise and do not use mobility aids.
I am willing to commit to the full 12 week programme
IMPORTANT NOTICE: The information collected in this questionnaire is strictly confidential, and for use by Programme staff only. Together with information collected at each of the sessions, it will be used to guide your treatment. In some cases, anonymised data may also be submitted to our public health partners for research purposes. Please discuss any concerns you may have regarding this information with the clinic staff at any time. If you do not wish for your data to be used in this way, then please let the team know at the time of booking and we can discharge you from the programme.