Questionnaire

Questionnaire

Thank you for taking the time to fill out this form. Please answer each question as specifically as possible. Once you fill out this form, a member of our team will contact you, discuss your situation and allocate a practitioner to suit you. The information collected here is kept confidential within our organisation, it will be available to be viewed by all members of our team.
Full Name*

First NameLast Name
Email Address*
example@example.com
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
What is your gender?*
What is your home suburb?*
What is your occupation?*
How did you hear about us?*

Google searchInstagramOther social mediaFriend/FamilyAllied health practitioner (Physio, Chiro, Massage therapist)Have been following FP for a long timeFlyerPromotionChat GPT/AIOther
What is the best way to contact you? (you can choose more than one option)*

CallSMSEmail
Why do you want to do Functional Patterns?*
Are you in chronic pain? (pain lasting >3 months)*

YesNo
What is your current pain score?*

1/102/103/104/105/106/107/108/109/1010/10No pain
If yes, please elaborate on the nature of your chronic pain.
Are you overcoming an injury?*

YesNo
If yes, please elaborate on the nature of your injury.
Do you have any relevant reports, x-rays, or any other medical imaging scans you'd like to show us? If yes, please upload them below.

Cancelof
Are you currently doing any of the following activities? (Check all that apply)*

Weightlifting of any kindYogaPilatesRoutine stretching or stretch therapyChiropractic therapyPhysiotherapyNone of the above
If you're participating in anything else outside these methods, please elaborate.
How willing are you to stop your current form of activities? (1 being completely unwilling, 5 being most willing)

12345
Do you play any recreational sports or activities?*

YesNo
How willing are you to stop these activities during your recovery/while initially learning Functional Patterns? (1 being completely unwilling, 5 being most willing)

12345
Do you currently include grains in your diet? (things like bread, rice, pasta, quinoa)*

YesNo
If yes, how willing are you to changing your diet if presented with information that grains can impact your recovery and health? (1 being completely unwilling, 5 being most willing)12

12345
Are you vegan, vegetarian, or anything else of this nature?*

YesNo
If yes, please expand on the nature of your diet, including why you currently follow this diet and why you may be avoiding animal products.
If yes, how willing are you to changing your diet if presented with information that a diet containing animal products is essential to your recovery and health?

12345
Do you currently smoke or vape?*

YesNo
If yes, please specify how often
Do you drink alcohol?*

YesNo
If yes, please specify how often
Do you consume caffeine?*

YesNo
If yes, please specify.
Are you currently a fitness or health professional, movement coach, or any sort of health therapist?*

YesNo
Have you completed the 10 week online course?*

YesNo
Our practitioners are at different levels of certification and experience. If you have a preference please select below. Please note that our price structure is reflective of this and your preference will have a different rate. For reference please see our schedule of fees in the terms and conditions and only select once you have reviewed the rate. Link at the end of the form. Human Biomechanics Specialist (HBS) and Human Foundations (HF)*

HFHBS 1HBS 2HBS 3HBS 4No preference
What are your goals and expectations?*
What are your best days and times to train? Please specify, as practitioners only have specific availability.*
Functional Patterns Sydney Pty Ltd will send you a secure link for pre payment of your Initial Consultation. Payment will need to be made to confirm your session.

Agree
How did you hear about us?*
Questionnaire

Thank you for taking the time to fill out this form. A member of our team will contact you, discuss your situation and allocate a practitioner to suit you.
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