Pre activity Form

Name*
First Last
Medicare No
DVA File No
Occupation
Date of Birth
MM slash DD slash YYYY
Email*
Phone Number*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact Person
First Last
Contact Number
Relationship
How did you hear about us?

Lifestyle
Describe your current weekly physical activity/exercise routine
Do you smoke cigarettes?
- Yes
- No
Do you drink alcohol on a daily basis?
- Yes
- No
How many standard drinks per day?
MUSCULOSKELETAL
Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise (e.g. Osteoarthritis, Multiple Sclerosis, Scoliosis)?
- Yes
- No

Why did you come to the session today and what do you want to leave with?
Do you know why your doctor has referred you to see an Exercise Physiologist?
What have you been trying already to manage the pain/condition?
Think about what you would like to achieve in 3 months. Now what do you know about how you can achieve this goal?
What are your accepted conditions as stated on your DVA card? (if applicable)
Name
This field is for validation purposes and should be left unchanged.

Lifestyle