Questionnaire

Initial Consultation Questionnaire & Medical Form

Thank you for taking the time to complete this form prior to your Initial Consultation. If completing it using a phone or tablet, use a landscape orientation for ease of access.
Full Name*
E-mail Address*
Contact Number*
Date of Birth*

DayMonthYear
What is your gender?*
What is your home suburb?*
What is your occupation?*
How did you hear about me?*
Why do you want to do Functional Patterns?*
Do any of the following medical conditions apply to you?*

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 other conditions that may require special consideration for you to exercise?None of the above apply to me.
If you answered 'YES' to any of the questions above, please seek guidance from an appropriate allied health professional of medical practitioner prior to undertaking exercise.
Do any of the following apply to you?*

Family history of heart disease (e.g. stroke)Been told you have high blood pressureBeen told you have high cholesterol/blood lipidsBeen told you have high blood sugar (glucose)Currently taking prescribed medication(s) for any condition(s)Have spent time in hospital for any condition/illness/injury during last 12 monthsPregnant or given birth in last 12 monthsHave any undiagnosed muscle degenerative conditionsNone of the above apply to me
If yes, please elaborate.
Are you in chronic pain? (pain lasting >3 months)*

YesNo
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.

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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)*

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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)

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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)

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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?

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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 Functional Patterns 10 Week Online course?*

YesNo
What are your goals and expectations?*
If training with me at Glenhaven, what times on a Tuesday and Thursday are best for you to train?
CANCELLATION: I require a minimum of 24 hours notice if you wish to cancel or reschedule any appointment. Non-attendance to a booked appointment, with no reasonable explanation, will attract a 100% charge. This policy ensures other clients are able to access my services rather than being put on a waiting list or turned away.
Please select "I Agree" below, that you understand the cancellation policy*
WAIVER: "I understand that Jonathan Sealey is not able to provide me with medical advice with regard to my medical fitness. The information gathered in this form is used as a guideline to the limitations of my ability to exercise. I will not hold Jonathan Sealey liable in any way for injuries that may occur while I am training."
Please select "I Agree" below, that you understand the above statement *
MEDIA CONSENT: By signing this form you consent to be in photo and video content created by me used for social media promotion. (I will always consult with you before publishing any content and discuss the option to anonymise your identity).
Please select "I Agree" below, that you give consent *
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Initial Consultation Questionnaire & Medical Form