NEW PATIENT FORM WIDE BAY EXERCISE PHYSIOLOGY

EXERCISE PHYSIOLOGY NEW PATIENT FORM
Please upload here any direct referrals, relevant scans or imaging.

You may attach your GP Medicare Care Plan, DVA D904 referral, WorkCover Work Capacity Certificate. You may also upload relevant scans if appropriate such as knee MRI for leg pain etc.
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How did you hear about us?*
Full Name*
Date of Birth*

DayMonthYear
Date
Just a few things before we move on

We'd love for you to quickly check out terms and conditions below:
If you've got an appointment and cannot make it, you MUST contact us to let us know. For your convenience, we will send you an SMS reminder 1 day before your appointment. Click YES to consent to a pre-appointment text reminder to the mobile number provided below*

Yes
Cancellation Policy: I agree that failure to provide notice of cancellation within 24 hours of an appointment (regardless of reason) will result in a 100% cancellation fee.*
Must select drop down and click "I AGREE"
Address*
Mobile*
Email*
example: lets.get.results@widebayep.com.au
Emergency contact (name, relationship and number): Referring physician (if applicable):
Emergency contact name relationship and number*
Example: John Smith, Ex-ex Father-in-law, 0412345678
Referring physician (if applicable)*
Example: Dr. Payne N. Suffer @ The Wobble Clinic
Injuries/surgeries (including joint replacements) Medications & dosages*
Medications & dosages*
OR send a photo of these to: appointments@widebayep.com.au if this makes it more convenient
Allergies*
Not specific to food but rare reactions such as chlorine (for water based) OR to sports-strapping tape
Past medical history*
E.g Double bypass 2014, ACL injury & surgery 2018 etc.
Current medical conditions*
Ongoing health issues that may be your primary concern
Family history health and conditions (relevant to exercise)*
Example: Father was type-2 diabetic, Mother has Parkinson's Disease. Father was office worker, Mother was a runner etc.
EXERCISE HISTORY
My exercise goals are:*
E.g: I want to start doing (type of movement) without (type of concern/restriction) OR sports specific orientated. Get REALLY specific with this one. Less specific = less likely to achieve
Previous experience with exercise*
Example: "Squash player until knee pain few years ago" OR "casual golf hits at hometown"
Current exercise routine*
Example: I lift weights for my bone density 3x p/wk OR casual walk with the dog OR nothing currently, reaching for my goals previously mentioned.
SMOKING HISTORY USE*
Example: N/A or 1 packet of _____ per week.
ALCOHOL HISTORY USE*
Example: One case of beer a week, 1 glass of wine a night etc.
What are your current sleep patterns?*
Example: "Sleep at ___ and wake up __ but I get up __ times in the night" or "About ___ hours of sleep per night"
How do you view your current dietary habits?*
Why do you think this?*
Has a dietician informed? Has your health been impacted as a result of habits?
How do you view your current hydration habits?*
Relating to amount of water consumed in the day or artificial drinks.
Occupation*
Example: Concreter 30 hours a week, admin worker 38 hours a week, retired teacher or N/A
Height in cm and Weight in kgs (if known)*
What will you sacrifice to improve your health and lifestyle? If you are serious, then why?*
Environment I want our consultations to be:*
Informed Consent

Exercise Physiology (EP) involves the prescription of a number of stretches, exercisesand movements. The EP's administering treatment are all appropriately qualified and covered by theappropriate insurances.
Your informed consent is required for all treatments at our practice. Please read the following and tick where agreeable:*

The techniques used during the course of treatment will always be discussed with you, outlining the possible benefits and risks, and whether the treatment is conventional or experimental.You have the right to withdraw your consent at any time, and treatment will cease.If you become uncomfortable at any time, or wish to discuss your treatment, you have the right to do so.All forms of treatment carry some risks. These will be outlined to you, and you have the sole discretion of continuing or discontinuing treatment.Your medical information may be disclosed to other health professionals that are caring for you (GP, Physio, Specialist, Podiatrist, Chiro, Insurance company, Rehabilitation consultant, Employer only if WorkCover.I give consent for treatment and agree to the risks and benefits outlined. This consent remains valid until such time as I withdraw it. I have read and fully understood the clinic Privacy Policy and Consent Policy
Assessment & Privacy: For assessment purposes (e.g., posture, movement analysis, muscle activation), you may be asked to adjust or remove certain outer garments. This may not be applicable to all patients. It will always be discussed with you beforehand, your comfort and privacy will be respected at all times, and you may decline on the day without affecting your care*

I understand that I may withdraw my consent at any time regarding this
Assessment & Privacy: We may use a contracted virtual administrative assistant, which may be based offshore, to assist with processing patient registration information (e.g., data entry and appointment administration). Any access to personal information is limited to what is necessary, is subject to strict confidentiality requirements, and is managed using secure systems and access controls. We take reasonable steps to protect your personal information and handle it in accordance with applicable privacy laws*

I Consent
Signed date*

DayMonthYear
Date
Your signature*
I have reviewed and understand the information provided during this initial consultation. I acknowledge that the exercise program and recommendations are based on the information. I have provided about my medical history, goals, and expectations.
IMPORTANT: Please click the SUBMIT button above then "sign document" on next page to submit the form. Confirmation of sent will re-direct you to our website home page

Note: Some blank spaces in the next page will be gone through, assessed and filled out on the day.
Should be Empty:

EXERCISE PHYSIOLOGY NEW PATIENT FORM

Just a few things before we move on

EXERCISE HISTORY

Informed Consent

IMPORTANT: Please click the SUBMIT button above then "sign document" on next page to submit the form. Confirmation of sent will re-direct you to our website home page