APSS

Fortify Movement & Health

Please complete this new client form to the best of your ability.

Your Details

First Name *

Last Name *

Preferred Name

Date of Birth *

Address Line 1 *

Address Line 2

Suburb *

Postcode *

Contact Number *

Email *

Occupation

Emergency Contact Name/Relationship

Emergency Contact Number

Your GP's Name?Please provide the name of your GP.

GP's Practice?Please provide your GP's practice name and location.

Tell us about yourself

Do you currently have any injuries? If yes, please provide details.

Do you have any health conditions? If yes, please provide details.

Are you, or have you been exercising recently? If yes, please describe.

Have you had a Physio, Exercise Physiologist or Personal Trainer before? If yes, please describe your experience.

How would you describe your current health and fitness?

What are your current health and fitness goals?

How will you feel when you achieve the goals above?

Adult Pre-Exercise Screening

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

YesNo

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

YesNo

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

YesNo

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

YesNo

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

YesNo

Do you have any other conditions that may require special consideration for you to exercise?

YesNo

Family history of heart disease (e.g. stroke, heart attack)?

YesNo

Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?

YesNo

Have you been told that you have high blood pressure?

YesNo

Have you been told that you have high cholesterol/ blood lipids?

YesNo

Have you been told that you have high blood sugar (glucose)?

YesNo

Are you currently taking prescribed medication(s) for any condition(s)? These are additional to those already provided.

YesNo

Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?

YesNo

Are you pregnant or have you given birth within the last 12 months?

YesNo

Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise?

YesNo

Training sessions with Fortify Movement & Health maybe photographed or videoed. These may be used in but not limited to print or digital platforms such as social media platforms for marketing or instructional purposes. Do you give consent?

YesNo

Is there any other information you would like to provide?

How you hear about us?

Statement:

I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.

Full Name

Signature

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