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
Format: (000) 000-0000.
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?
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
Medical Conditions: Do any of the following apply to you?
Medical Conditions: Do any of the following apply to you?
Please explain any checked items from above
Medical Conditions: Please tick the following that apply
Medical Conditions: Please tick the following that apply
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.
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.”
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)
Signature
Date

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Date
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Client Application Form