Patient Intake Form
Patient Information
Name
(Required)
First
Last
Date of Birth
(Required)
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
Year
2027
2026
2025
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
Email Address
Phone Number
Address
Street Address
Suburb
Post Code
Occupation
This field is hidden when viewing the form
Emergency Contact Details
This field is hidden when viewing the form
Emegency Contact Name
This field is hidden when viewing the form
Emergency Contact Number
This field is hidden when viewing the form
Relationship
Funding & Referral Information
Which of the following applies to you:
Private Patient / Client
GP Referral
DVA - Veterans
NDIS
Aged Care - Support At Home / CHSP
TAC - Road Accidents
WorkCover / WorkSafe
Other / Unsure
DVA Card Type
White Card
Gold Card
DVA Number
WorkCover Claim Number:
WorkCover Claims Paying Organisation
Allianz
CGU
EML
Gallagher Bassett
XChanging
Unknown / I'm Not Sure
WorkCover Insurance Agent
TAC Claim Number:
Date of Injury / Accident:
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 / Osteopenia
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.
This field is hidden when viewing the form
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
This field is hidden when viewing the form
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?
This field is hidden when viewing the form
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?
378 Mt. Alexander Rd
Travancore VIC, 3032
