PRE-ASSESSMENT FORM

PRINT OUT PAPER VERSION

ONLINE FORM

Below you will find a detailed consultation form which must be complete prior to your first visit with Body Motion. Please make sure you fill in all required fields and remember to answer honestly, for this will help guide your program/recovery.


    PERSONAL INFORMATION

    First Name

    Last Name

    Your Address

    City

    State

    Postcode

    Your Mobile

    Your Home Number

    Email Address

    Gender

    D.O.B

    Emergency Contact


    MEDICAL HISTORY

    Occupation

    GP Name and Address

    Funding: Private

    Health Fund

    NDIS

    Medicare (CDM/GP management plan)

    DVA

    How did you hear about us

    If Friend or Family are you happy to tell us who so we can thank them?

    Please tick YES or NO for the following:

    Diabetes
    Asthma, COPD or respiratory conditions
    Epilepsy or Seizures
    Neurological Disorders, Anxiety, Depression
    High Blood Pressure
    Heart Disease
    Do you smoke
    Are you pregnant
    Broken bones, sprains, dislocations
    Arthritis - Osteoarthritis, Rheumatoid, Juvenile
    Recent surgery, or hospitalisation
    Headaches, migraines, concussion

    Chief complaint - What is the reason for booking a consult?:

    Medications:

    Medical / Surgical History:

    Sports / Activities:


    CONSENT AND SUBMIT

    Consent to Treatment

    I am of sound mind to make the informed choice to participate in any ongoing exercise programming conducted by Body Motion. I understand this document in full, and have given an honest and complete account of my history. I consent to assessment, treatment, and the possible use of videography for assessment and treatment purposes while working with Body Motion.

    Confidentially
    I agree and grant permission for Body Motion to disclose, where reasonably necessary, any required medical and personal information to third parties including: general practitioners, physiotherapists, hospitals, insurance agencies acting on your behalf and other health professionals in the event that reasonable information is required to be able to provide optimal services for your health and physical progression.

    Consent: (Parental / Guardian for patients under 16)