Exercise Physiology New Patient Form
Patient Information
Name
(Required)
First
Last
Date of Birth
(Required)
Day
Day
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Year
Year
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Email Address
Phone Number
Address
Street Address
Suburb
Post Code
Occupation
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Emergency Contact Details
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Emegency Contact Name
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Emergency Contact Number
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Relationship
Funding & Referral Information
Have you been referred to our clinic or do you have any of the following:
DVA
GP Referral
NDIS
TAC
WorkCover / WorkSafe
Other
DVA Card Type
White Card
Gold Card
WorkCover Claim Number:
TAC Claim Number:
Date of Injury:
NDIS Number:
Medical Information / GP Details
GP Practice Name:
Name of your GP (General Practitioner) / Doctor?
Do you have Private Health Insurance?
Yes, I have Private Health Insurance
No, I do not have Private Health Insurance
Health Check & Current Medications
Please check the box to the left of the condition if you have any of the following:
Heart Disease
Pulmonary (Lung) Disease
Metabolic Disease
Family History of Heart Disease
High Blood Pressure
High Cholesterol
Sedentary Life
Chest Pain
Dizziness
Shortness of Breath
Irregular/Accelerated Heart Rate
Osteoporosis
Arthritis/Joint Pain
Back Pain/Spine Disorder
Musculoskeletal Pain/Injury
Hernia
Recent Surgery
Hypoglycemia
G.I. Disorder
High Triglycerides
Cancer
Prenatal / Postnatal
Anemia
Are you taking any Medications, pills, tablets or supplements that may effect your training?
No
Yes
If Yes, please list or describe your current medication.
Do you have any current injuries or have you suffered any serious injuries in the past?
No
Yes
If Yes, please give a breif description of the injuries.
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Exercise History
Exercise History
Have you ever seen an Exercise Physiologist, or had a Personal Training in the past?
No
Yes - I've seen an Exercise Physiologist before
Yes - I've seen a Personal Trainer before
Yes - I've done Group Fitness Exercise / Classes before
Can you give a brief description of your past involvement with Exercise Physiology, Personal Training, Group Training? (Where, when, likes / dislikes)
How many days a week are you currently exercising? (0-7)
0 - None at the moment
1 - One day a week
2 - Two days a week
3 - Three days a week
4 - Four days a week
5 - Five days a week
6 - Six days a week
7 - Exercise everyday
What does your current exercise routine look like? (i.e. 30min weights, 30min cardio, 60min walking, ect)
How many days a week would you ideally like to see yourself exercising?
None - I don't want to regularly exercise
Once a Week
Twice a Week
Three Times a Week
Four Times a Week
Five Times a Week
Six Times a Week
Type of Person Who Exercises Everyday
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Current Health & Fitness Goals
Current Health & Fitness Goals
What is your main health goal, and what are you looking to achieve?
What are the biggest challenges you face in trying to achieve those goals on your own?
SCALE (1-10) How committed are you to reaching your goal? (Be Honest)
10 - 100% It's My #1 Priority!
9
8
7
6
5
4
3
2
1 - Not Interested or Committed At All
Why did you choose a 6? You don't need to change your answer above, but how do we get you to an 8 or above?
Why did you choose a 5? You don't need to change your answer above, but how do we get you to an 8 or above?
Why did you choose a 4? You don't need to change your answer above, but how do we get you closer to an 8 or above?
Why did you choose a 3? You don't need to change your answer above, but how do we get you closer to an 8 or above?
Why did you choose a 2? You don't need to change your answer above, but how do we get you closer to an 8 or above?
Why did you choose a 1? You don't need to change your answer above, but how do we get you closer to an 8 or above?
Fantastic! If you were to train for the next 6 months to a year, what would you like to see happen? What is your ideal scenario when working with our team?
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Anything Else You Wish to Add?
Anything Else You Wish to Add?
Is there anything else you think may be relevant to let our Exercise Physiology team know before your initial consultation?