Where on your body? *

Title *

First Name *

Last Name *

Gender *

Date of Birth *

Email Address *

Home Address *

Suburb *

State *

Post Code *

Emergency Contact

Name (Next of Kin + Parent Guardian) *

Relationship *

Phone *

Strong Kids/Strong HIIT

Provide details *

Does your child have any chronic disability or chronic illness? *

YesNo

Provide details

Does your child take any medications? *

YesNo

Provide details

Has your child had surgery in the last 12 months? *

YesNo

Provide details

Has your child broken any bones in the last 12 months? *

YesNo

Provide details

Please inform us if there is anything else regarding your child's health that has not been mentioned

Doctor *

Medical Practice *

Medicare No *

Line *

Expiry Month *

Expiry Year *

Doctor Referral / Care Plan

Browse

(please also bring these with you to your appointment)

Private Health Cover

Private Health Cover

Provider *

Card No. *

Line *

Health Concession / Pension Card

Aged Pension Card

Card No

Upload photo of card

Browse

National Disability Insurance Scheme (NDIS)

National Disability Insurance Scheme (NDIS)

NDIS Number *

Management Type *

Insurer *

Claim No. *

Date of Injury *

Department of Veteran Affairs (DVA)

Department of Veteran Affairs (DVA)

Card Type *

White Card Clinical Text

Card Number *

Condition

Expiry Month *

Expiry Year *

Card Photo

Browse

Upload photo of referral

Browse

ESSA (Exercise and Sports Science Australia) Pre-Screen

This screening tool is part of the Adult Pre-Exercising Screening System (APSS) that also includes guidelines on how to use the information collected and to address the aims of each stage. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise & Sport Science Australia, Fitness Australia, Sports Medicine Australia or Exercise is Medicine for any loss, damage, or injury that may arise from any person actingon any statement or information contained in the system.

STAGE 1 (COMPULSORY)

AIM: To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual.

IF YOU ANSWERED "YES" to any of the 6 questions, guidance will be given from your appropriate allied health professional or medical practitioner prior to undertaking exercise.

IF YOU ANSWERED "NO" to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/exercise per week.

7. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities

Frequency
(number of sessions per week)

Light

Moderate

Vigorous/High

Duration
(total minutes per week)

Light

Moderate

Vigorous/High

Weighted physical activity/exercise per week

I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.

Client signature

Draw signature|Type signatureClear

Date

Essa.org.au. 2021. Adult Pre-Screening Tool . [online] Available at: <https://www.essa.org.au/Public/ABOUT_ESSA/Adult_Pre-Screening_Tool.aspx> [Accessed 2 March 2021].

SOZO Pre-Screen Form

To help us prepare for your consultation we would like to gather some information to setup a profile in our SOZO bioimpedance device.

The SOZO will calculate your current skeletal muscle mass. We can monitor for any changes (eg. fluid changes in your limbs) into the future.

Primary Diagnosis *Type of cancer / lymphoedema / other condition

HeightHeight in centimeters. If unsure, ask to be measured.

WeightWeight in kilograms. If unsure, ask to be weighed.

What is your dominant hand? *

LeftRight

Affected area details..

Have you had surgery? *

YesNo

Please provide details..Describe location(s) on body, date of surgery, etc.

Have you had surgery to remove lymph nodes? *

YesNo

Please provide details..Describe location(s) on body, date of surgery, etc.

Have you had chemotherapy treatment? *

YesNo

Please provide details..Date completed, or date commenced, or date due to commence.

Have you had radiation treatment? *

YesNo

Please provide details..Describe location(s) on body, date of treatment, side affects, etc.

Do you wear a compression garment? *

YesNo

Please provide details..Describe what you wear, how often?

Please rate your current experience of the treatment related symptoms listed below.

0 (None) - 10 (Worst Immaginable)

Additional comments..

CANCELLATION POLICY - A FEE OF $65.00 WILL BE CHARGED IF YOU FAIL TO ATTEND YOUR APPOINTMENT. 24 HOURS NOTICE IS REQUIRED FOR CANCELLATIONS.

PhysioHealth will seek reimbursement from patient of all funds not reimbursed through third party e.g. Insurance or Medicare *

A patient may be expected to remove certain articles of clothing to allow for a detailed musculoskeletal assessment
A patient is entitled to bring a chaperone if they so wish to. *

PhysioHealth & sports injury clinic accepts no responsibility for the treatment received. Any professional liability is between the patient and the individual therapist [all PhysioHealth & sports injury clinic physiotherapists and Exercise Physiologists are insured through their respective insurance companies]. PhysioHealth & sports injury clinic adopts assurance protocols in accordance with the clinical guidelines as are specified by the Australian Physiotherapy Association and Exercise & Sports Science Australia. *

Acknowledgement and assumption of risk: You understand and acknowledge that; you will not hold us liable for any personal injury, damage to or loss of belongings which may arise from ours, our staff or clients. You take on full responsibility for potential risks associated with the use of gym equipment in a shared space such as the risk of slips, trips and falls. *

I consent for PhysioHealth to capture pictures/videos of yourself at times throughout your treatment for posting on our website or Facebook page. PhysioHealth will always ask before taking a photo or a video.

Do you have any other comments or questions?

Registration

Strong Kids/Strong HIIT

Medical

ESSA (Exercise and Sports Science Australia) Pre-Screen

Health Information

Symptom Rating

Consent