Functional Biomechanics - Initial Consultation & Medical Form

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Full Name* This field is required.

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E-mail Address* This field is required.

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Phone Number* This field is required.

Country Code

Phone Number

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Date of Birth* This field is required.

5

Home Suburb* This field is required.

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Occupation* This field is required.

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Emergency Contact Name * This field is required.

First Name

Last Name

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Emergency Contact Number* This field is required.

Country Code

Phone Number

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How Did You Hear About Me?* This field is required.

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Has a doctor ever told you that you have a heart condition?* This field is required.

YESNO

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Please provide more details on the heart condition.* This field is required..

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Do you experience chest pain during physical activity?* This field is required.

YESNO

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Please provide more detail on your chest pain experienced during physical activity.* This field is required..

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Have you experienced chest pain at rest in the past month?* This field is required.

YESNO

15

Please provide more detail on your resting chest pain.* This field is required..

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Do you experience dizziness, fainting, or loss of balance?* This field is required.

YESNO

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Please provide more detail around your dizziness, fainting, or loss of balance.* This field is required..

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Do you have high blood pressure?* This field is required.

YESNO

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Please provide more detail around your high blood pressure.* This field is required..

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Have you been diagnosed with a respiratory condition (such as asthma)?* This field is required.

YESNO

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Please provide more detail on your respiratory condition.* This field is required..

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Do you have diabetes or blood sugar regulation issues?* This field is required.

YESNO

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Please provide more detail around your blood sugar regulation.* This field is required..

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Have you ever had a stroke or neurological condition affecting movement or balance?* This field is required.

YESNO

25

Please provide more detail around your neurological condition.* This field is required..

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Do you currently experience pain, injury, or physical limitations that may affect exercise?* This field is required.

YESNO

27

Please provide more detail around your pain, injury or physical limitations.* This field is required..

28

Have you undergone surgery or major medical procedures in the past 5 years?* This field is required.

YESNO

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Please provide more detail around your surgery or major medical procedures.* This field is required..

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Has a healthcare professional advised you to avoid or modify certain forms of exercise?* This field is required.

YESNO

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Please provide more detail around the advise around avoiding or modifying exercises.* This field is required..

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Is there any other medical condition or concern that may impact your ability to train safely?* This field is required.

YESNO

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Please provide more detail around the medical condition or concern impacting your ability to train safely.* This field is required..

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Please list any medications you are currently taking that are relevant to exercise, recovery, balance, blood pressure, or performance.* This field is required.Write 'No Medications' if N/A

35

Are you currently experiencing pain in your body?

YESNO

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Please describe any current pain, injuries, movement limitations, surgeries, recurring issues, or medical conditions relevant to exercise or movement.* This field is required.Include current pain levels. Scale 1-10 (e.g. 5/10), 1 being a low pain level.

37

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.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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What movements, activities, sports, or physical tasks would you most like to improve in, or return to?* This field is required.

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How physically active are you currently?* This field is required.

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What forms of exercise, sport, or training are you currently doing?* This field is required.

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Are you currently doing any of the following activities/therapies?* This field is required.Check all that apply

Weightlifting of any kind

Yoga

Pilates

Routine stretching or stretch therapy

Chiropractic therapy

Physiotherapy

Osteopath

Podiatrist

None of the above

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How willing are you to stop sports, activities or other forms of training and therapy during your recovery/while initially learning the Functional Patterns methodology?* This field is required.(1 being completely unwilling, 5 being most willing)

1

2

3

4

5

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How would you describe your work and daily activity levels?* This field is required.

Mostly sitting

Mixed sitting/standing

Mostly standing/walking

Physical labour

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Average sleep per night?* This field is required.

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Current stress levels?* This field is required.

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Are you vegan, vegetarian, or anything else of this nature?* This field is required.

Yes

No

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What diet do you follow and why?* This field is required.

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Do you currently include grains in your diet? (things like bread, rice, pasta, quinoa)* This field is required.

Yes

No

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If yes, how willing are you to changing your diet if presented with information that grains can impact your recovery and health?* This field is required.(1 being completely unwilling, 5 being most willing)

1

2

3

4

5

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Do you currently smoke or vape?* This field is required.

Yes

No

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If yes, please specify how often.* This field is required.

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Do you drink alcohol?* This field is required.

Yes

No

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If yes, please specify how often.* This field is required.

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Do you consume caffeine?* This field is required.

Yes

No

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If yes, please specify how often.* This field is required.

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What are your goals and expectations?* This field is required.

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Have you completed the Functional Patterns 10 Week Online course?* This field is required.

Yes

No

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If training with me at Glenhaven, what times on a Tuesday and Thursday are best for you to train?* This field is required.If other weekdays/times are preferred, please also ask.

60

CANCELLATION POLICY

I require a minimum of 24 hours notice if you wish to cancel or reschedule any appointment.

Non-attendance to a booked appointment will attract a 100% session fee charge.

This policy ensures other clients are able to access my services rather than being put on a waiting list or turned away.

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Please select "I Agree" below, that you understand the cancellation policy* This field is required.

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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.

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Please select "I Agree" below, that you understand the above statement * This field is required.

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MEDIA CONSENT

By signing this form you consent to be in photo and video content created by Functional Biomechanics used for social media promotion.

I will always consult with you before publishing any content and discuss the option to anonymise your identity.

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Please select "I Agree" below, that you give consent * This field is required.