EXERCISE PHYSIOLOGY NEW PATIENT FORMComplete Online Form Here.Patient DetailsFirst Name*Last Name*Date of BirthAgeMobile*Email*Street AddressCityStatePostcodeName of DoctorPractice LocationName of Private Health FundHave you visited an Exercise Physiologist before? Yes/No, If yes, whyWhat is your reason for your consultation?Have you had a fall in the last 12 months? Yes/No, If yes, when and how did the fall occurOccupationHow did you hear about AMS?How did you find out about Active Movement Studio?*How did you find out about Active Movement Studio?Google seachGoogle mapsFacebookInstagramFlyerPromotionWord of mouthDoctor referralMedical/Injury History & MedicationHave you ever been diagnosed with any of the following conditions? Heart condition (angina, stent, pacemaker) Coronary heart disease Heart murmur Stroke or transient ischemic attack Hypotension or hypertension Lung conditions (asthma, emphysema, bronchitis Chronic obstructive pulmonary disease (COPD) Type 1 or 2 diabetes Metabolic syndrome or insulin resistance High cholesterol (dyslipidaemia) Rheumatic fever Cancer (breast, colon) Arthritis (rheumatoid, osteo, gout) Osteoporosis or ostepenia Stomach or duodenal ulcer Henria (inguinal, umbilicus, hiatus) Pregnancy Elilepsy depression anxiety Parkinson's disease Multiple sclerosis Motor neuron disease Frozen shoulder Neck, shoulder, back or knee pain Other, please specific belowOther, please specify...Has your doctor ever diagnosed you with a heart or lung condition? If so, have you attempted a rehabilitation program?*Do you experience any unexplained pains in your chest at rest or during physical activity/exercise?*Do you have low or high blood pressure? If either, are you currently medicated to manage your blood pressure?*Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*Do you get unusually short of breath when engaging in any physical activity/exercise?*If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months?*Do you have any diagnosed muscle, bone or joint problems? Do any of these conditions cause you pain?*Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?*Have you been involved in any traumatic event where you sustained a injury that required medical attention?*When was your last health assessment done with your doctor?Did you have a blood test?AnswerYESNOAny abnormalities?Do you give permission for Active Movement to request a copy of your blood tests from your doctors if required?AnswerYESNOMedicationAre you currently taking any prescription medications?YES - complete list belowNOList of medicationsName of MedicationDoseReason for Prescription Exercise HistoryAre you currently engaging in regular structured exercise?AnswerYES - please list belowNOList your current weekly exercise regimeType of exerciseFrequency/weekDuration List any exercise dislikesIn general, how would you rate your current health? 1 = worst & 10 = best 1 2 3 4 5 6 7 8 9 10How many hours per day do you spend seated? 0 - 2 2 - 4 4 - 6 6 - 8Goals & OutcomesGoal Setting (set up to 3 goals per category)Immediate (>1 week)Short Term (<3 months)Long Term (>6 months) Patient Information & ConsentInformed Patient Consent* Select All I hereby acknowledge that all the information I have provided to Active Movement Studio is accurate to the best of my knowledge. If unsure of any information I will inform my practitioner. I understand that I may require medical clearance from my general practitioner to determine my suitability to commencing a regular exercise program. As a patient of Active Movement Studio it is my responsibility to notify my practitioner if there are any changes to my medical condition including changes in medication. I give permission for Active Movement Studio to contact my general practitioner or other allied health professionals to obtain any relevant information regarding my condition. I understand that engaging in regular physical activity can cause potential risk of injury or bodily harm and I will not hold the staff of Active Movement Studio liable if this occursPrivacy Policy* Active Movement Studio is committed to ensuring that all personal information that is disclosed in consultations and sessions will remain confidential and only be accessible by appropriate staff. All personal information is stored in a secure location protected from unauthorized access, modification or disclosure. All staff are regularly reminded of the importance of this matter and any breach in privacy is not tolerated.AMS Rescheduling Policy* Select All Your reserved consultation time has been specifically allocated to you. To achieve maximum improvements in the shortest possible timeframe, it is vital that you maintain your advised schedule of care. If you are unable to make your appointment time, please note the following applies: Did Not Arrive (no courtesy call or notification) = 100% Fee Applies Cancellation within 24 hours = 50% Fee Applies Cancellation within 6 hours = 100% Fee Applies Upfront Packages - Cancellation with 24 hours = 100% Fee Applies Our AMS Rescheduling Policy aligns with our core value ‘To positively impact as many lives as possible’. Sufficient notice enables us to make the appointment available to someone else. We thank you for your understanding and cooperation.Let's Stay Connected To maximise the benefit of your treatment, our practitioners strongly advise you subscribe to receive our tailored information. You will receive valuable health advice from our experts to help guide you to a successful outcome! Consent to Treatment* I have read and understand the above information, including the AMS Rescheduling Policy, and give my consent to treatment. I agree to this consent remaining valid until such time as I withdraw my consent. I also agree and give consent for my case to be discussed with AMS practitioners, treating doctor and 3rd party bodies if appropriate.Sign Here*
