Active Lives Exit Form Please provide the following information Name * Date of birth * 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date of birth (mandatory field) month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Date of birth (mandatory field) year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Telephone * Email * Course completion date * 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Course completion date (mandatory field) month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Course completion date (mandatory field) year 2024 2023 2022 2021 2020 2019 2018 Activity level after 12 weeks * Weight after 12 weeks * Please answer the following questions - select which response you feel is most appropriate I’ve been feeling optimistic about the future * None of the time Rarely Some of the time Often All the time I’ve been feeling useful * None of the time Rarely Some of the time Often All the time I’ve been feeling relaxed * None of the time Rarely Some of the time Often All the time I’ve been feeling interested in people * None of the time Rarely Some of the time Often All the time I’ve had energy to spare * None of the time Rarely Some of the time Often All the time I’ve been dealing with problems well * None of the time Rarely Some of the time Often All the time I’ve been thinking clearly * None of the time Rarely Some of the time Often All the time I’ve been feeling close to other people * None of the time Rarely Some of the time Often All the time I’ve been feeling confident * None of the time Rarely Some of the time Often All the time I’ve been able to make up my own mind about things * None of the time Rarely Some of the time Often All the time I’ve been feeling loved * None of the time Rarely Some of the time Often All the time I’ve been interested in new thing * None of the time Rarely Some of the time Often All the time I’ve been feeling cheerful * None of the time Rarely Some of the time Often All the time I’ve been feeling good about myself * None of the time Rarely Some of the time Often All the time Confidentiality The information you have provided on this form will be used to manage your self-referral onto the Active Lives programme, including to contact you if we have any queries or need to let you know about any changes. If you would like any further information about how we use your data, please speak to one of our staff or view our privacy policy here: www.lancaster.gov.uk/privacy-salc. The health information you have provided on this form will only be used to offer advice tailored to you, and to ensure that we do not provide you with any services which may be unsuitable or unsafe. We take your privacy very seriously, and will not pass your information to any other third parties for marketing purposes.
