Questionnaire

Client Application Form

This application is to train Functional Patterns with FP Human Biomechanics Specialist Alana Portelli. Please answer each question as specifically as possible.
Full Name*

First NameLast Name
E-mail Address*
example@example.com
Contact Number*
Emergency contact name *
Emergency contact number *
Date of Birth*

DayMonthYear
What is your gender?*
What is your home suburb?*
What is your occupation?*
Is your preference to train in-person, online, or a combination?*

In personOnlineCombination of in-person and online
Please give me a brief history of previous injury and treatment*
Please give me a brief summary of your exercise regimen, if any. *
Are you currently in any pain or discomfort? If yes, please elaborate on the nature of your pain*
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
Lifestyle preferences. Please tick the following that apply*

Weightlifting of any kindYogaPilatesRoutine stretching or stretch therapySee a regular allied health professional (physiology, chiropractor, massage)Long distance run (5+km at a time)Regularly eat grainsRegular alcohol consumption (>1/week)Regular coffee consumption (+1/day)Vegan/ plant based diet
Medical Conditions: Do any of the following apply to you?*

Heart Condition/ chest painCancerHigh blood pressureArthritisEpilepsyRegular smokerDiabetesOsteoporosisFatigue or lethargyHayfever/ sinus problemsAsthma/ respiratory problemsMuscle aches and painsMigraines/ headachesDigestive complaintsRecent surgeryHigh cholesterolPacemakerOesteoarthritisThyroid issuesPregnantOtherNone of the above
Please explain any checked items from above*
Medical Conditions: Please tick the following that apply*

Has your doctor ever told you that you have aa heart condition or ever suffered a stroke?Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?If you have diabetes (type 1 or type 2), have you had trouble controlling your blood glucose in the last 3 months?Do you have any undiagnosed muscle, bone or joint problems that 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?None of the above apply to me
Please explain any checked items from above*
What are your best days and times to train?*
What are your goals and expectations in the next 3-6months?*
How did you hear about me?*
Cancellation Policy: -I require a minimum of 24 hours notice if you wish to cancel or reschedule. Non-attendance to a booked appointment, with no reasonable explanation, will attract a 100% charge. This policy ensures other clients are able to access our services rather that being put on a waiting list or being turned away. Please tick the box below which confirms that you agree to this policy.*

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Wavier: please agree by ticking the box below, that you understand to the following statement “I understand that Alana Portelli is not able to provide me with medical advice with regard to my medical fitness. This information is used as a guideline to the limitations of my ability to exercise. I will not hold Alana Portelli liable in any way for injuries that may occur while I am training.”*

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Media Consent: -By signing this form you consent to be in photo and video content created by me used for social media promotion and website content. (I will always consult you before publishing any content and discuss the option to anonymise your identity)
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Client Application Form