EXERCISE PHYSIOLOGY NEW PATIENT FORM Complete Online Form Here. Patient DetailsHow did you hear about AMS?*How did you find out about Active Movement Studio?GoogleFacebookInstagramFlyerPromotionWord 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 below 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 10 How many hours per day do you spend seated? 0 - 2 2 - 4 4 - 6 6 - 8 Goals & 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 occurs Privacy 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. Active Movement Studio Rescheduling Policy Your reserved consultation time has been specifically allocated to you. To achieve maximum improvement 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, a minimum of 24 hours notice is expected for Exercise Physiology and Personal Training appointments. This enables us to make the appointment available to someone who really needs to come in for care. A courtesy phone call to reschedule your appointment is appreciated, otherwise a standard rescheduling fee of the cost of the service you requested will be incurred. We thank you for your understanding and cooperation. AMS Team. Let's Stay Connected I give AMS permission to register me to receive exclusive promotions, free health advice, hear the latest fitness trends, access our workout of the month and gain exclusive invitations to our workshops and more. Consent to Treatment* I have read and understand the above information and give my consent to treatment *
