APSS

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

If you need support completing this form, call us on 03 8383 3604

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

Have you been referred to Fortify Movement & Health?

YesNo

If yes, what's the reason for your referral?Did you know Exercise Physiologists use exercise like medicine to treat and manage health conditions?

What do you hope to get from your appointment?

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

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

Are you currently on any medications?

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 wellness goals?

How will you feel when you achieve the goals above?

Pre-Exercise Screening

At Fortify Movement & Health, we are big on promoting physical activity. This next section helps us know if there are any considerations we need to factor in when implementing physical activity into your week.

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

YesNo

If yes, if not previously mentioned above, please provide details.

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

If yes, please provide details.

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

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