Initial Consultation Form

Initial Consultation Form
Filling out this form is required PRIOR to your initial consultation. Once you submit this form, I (Daniel Tahmazis) will reach out to you to schedule your consultation as soon as I have availability that matches your indicated availability to train. Please ONLY fill this out if you are ready to potentially begin training***

The initial consultation is $135 and is the mandatory first step towards beginning training (whether 1:1 or 2:1 group training); the consultation is 90 minutes and consists of posture and gait assessment, a guide to myofascial release (self-massage), corrective exercises and program recommendation. Payment is due upon your visit to the facility.

I advise that you seek medical clearance and advice from a doctor prior to participation in the initial consultation and subsequent training. I do not share your information with anyone.
Any box with the * sign requires to be filled out

Please press SUBMIT at the bottom of the page once you have completed this form
Personal Details
Name*

First NameLast Name
Sex *
D.O.B *
(DD/MM/YYYY)
Email *
example@example.com
Phone Number *
Postcode
Instagram Username (if you have one)
How did you hear about my services?*
Occupation*
Emergency Contact*
Emergency Contact Relationship*
Emergency Contact Phone*
Medical Details
Do you have any of the following? (Tick one or more if they apply)

High Blood PressureCancerEpilepsyRegular SmokerDiabetesOsteoporosisOsteoarthritisRheumatoid ArthritisAsthmaRecent SurgeryHigh CholesterolPacemakerThyroid IssuesPregnantPost-PartumOther
Additional Notes
Please include any additional notes here for the listed items above
Please answer the following (leave blank if none apply)

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?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?If you have diabetes (Type I or Type II), have you had trouble controlling your blood glucose in the last 3 months?Do you have any undiagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?
Please give me a brief history of previous and/or current injuries, surgeries and treatment:
Do you suffer from chronic pain?*

YesNo
What would you consider to be a successful result for you in 3-6 months time?*
Current Diet & Exercise Regime
Please give me a brief summary of your current exercise, if any:
Do you currently see a regular health practitioner that falls under one of the following?

ChiropractorMassage TherapistOsteopathPhysiotherapistOther
Please select any of the following that apply: *

YogaCrossfitBarbell SquattingDeadliftingLong distance running (5+ km running at a time)CyclingOther
If you're doing exercise and/or therapy outside of these methods, please elaborate:
How willing would you be to stop or reconsider these current exercises/therapies if I believe they're inhibiting you from overcoming your goals. (1 being completely unwilling, 5 being very willing)

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What kind of training are you interested in?*

1-to-1 PT2-on-1 PTBoth of the above
What would be the best days/times for you to train? Please be as specific as possible as certain time slots are high in demand*
Please select any of the following that apply:*

Alcohol consumption (>1/week)Coffee consumption (1+/day)Eat grains regularly (1+/day pasta, rice, bread etc.)VeganVegetarianPescatarian
Please expand on the nature of your diet, foods you commonly consume or avoid and why that may be.
If I believe the nature of your diet could be affecting your progress or goals, how willing would you be to make changes to it? (1 being completely unwilling, 5 being very willing)*

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Please explain anything else you would like us to know!
RESCHEDULE/CANCELLATION POLICY INFORMATION
I (Daniel Tahmazis) require a minimum of 24 hours notice if you wish to cancel or reschedule.

RESCHEDULE: Should you wish to reschedule your appointment, please either call or message meon, 0430 737 092 or email me at contact@originbiomechanics.com to ensure you do not get a charged no-show fee (100% session price).

CANCELLATION: In the event you do not attend your scheduled appointment, with no reasonable explanation, you will incur a 100% payment fee for the session. This policy ensures other clients can access my services rather than being put on a waiting list or turned away.
Please type 'I Agree' if you accept to adhere to the cancellation policy above*
Terms of Service*

I accept the terms of service below
Physical exercise can be strenuous and subject to risk of serious injury. I urge you to obtain a physical examination from a doctor before using any exercise equipment or participating in any exercise activity.

You agree that by participating in physical exercise or training activities, you do so entirely at your own risk. Any recommendation for changes in diet including the use of food supplements are entirely your responsibility and you should consult a physician prior to undergoing any dietary or food supplement changes.

You agree that you are voluntarily participating in these activities and use of these facilities and premises and assume all risks of injury, illness, or death.

Myself, the trainer (Daniel Tahmazis) are also not responsible for any loss of your personal property.

You acknowledge that you have carefully read this "waiver and release" and fully understand that it is a release of liability.

You agree to release and discharge the trainer or instructor from any and all claims or causes of action and you agree to voluntarily give up or waive any right that you may otherwise have to bring a legal action against the trainer or instructor for personal injury or property damage. To the extent that statute or case law does not prohibit releases for negligence, this release is also for negligence.

If any portion of this release from liability shall be deemed by a Court of competent jurisdiction to be invalid, then the remainder of this release from liability shall remain in full force and effect and the offending provision or provisions severed here from.

By accepting the terms of service, I acknowledge that I understand its content and that this release cannot be modified orally.
Should be Empty:

Initial Consultation Form

Personal Details

Medical Details

Current Diet & Exercise Regime

RESCHEDULE/CANCELLATION POLICY INFORMATION