Survey Prescreening Survey Name D.O.B Occupation Who is your regular GP? Do you have private health care Yes No Do you have: Current Work Cover Claim Yes No Do you have: DVA Card Yes No Please list any orthopedic or musculoskeletal condition contributing to pain or injuryPlease tick your current level of pain associated with the above injury/concern on the scale below. 1 2 3 4 5 6 7 8 9 10 0 = No Pain | 10 = Extreme PainHow long have you had this injury/concern? 1-4 days 1-4 weeks 1-3 months 6-12 months Longer than 12 months Do you take any medications? Yes No Please list your medicines and the condition they are taken forDo you ever experience Chest Pain? Yes No Do you ever experience Shortness of breath Faint? Yes No Do you ever experience Dizzy Spells? Yes No DetailsHas your Doctor ever said that you have a heart condition? Yes No Do you have high blood pressure? Yes No Have you had any surgery in the past year? Yes No Do you ever experience changes in bladder or bowel control? Yes No Do you ever experience weakness in your arms or legs? Yes No Do you ever experience numbness or tingling? Yes No Additional Information for Exercise Physiology PatientsDo you currently or have you ever experienced any of the following? (Please tick)Risk FactorHigh blood pressureShortness of breathHigh cholesterolLight headednessTightness in chestDizzinessRespiratoryAsthmaEmphysemaOther pulmonary diseaseCardiovascularHeart attackIschemic heart diseaseStrokeHeart surgeryArrhythmiasMetabolicDiabetes Type 1 (IDDM)Gastrointestinal conditionDiabetes Type 2 (NIDDM)Liver conditionGoutKidney conditionMusculoskeletalBroken bonesRheumatoid AthritisFallsOsteoporisOsteoarthritisOtherCancerRecent surgeryEpilepsy or seizuresVision problemsPregnancyDetailsFamily historyDo you currently smoke cigarettes on a regular basis? Yes No Do you currently consume alcohol on a regular basis? Yes No Are you receiving treatment from any other health professionals for your condition? Yes No If yes, who is/are your treatment provider(s)?What would you like to achieve by participating in exercise rehabilitation or physical activity?What would you rate your motivation to participate in physical activity out of 10. Please choose on the scale below 1 2 3 4 5 6 7 8 9 10 Do you have any barriers to participating in physical activity? i.e. travel, cost, motivation Please describeDo you currently participate in structured physical activity? If yes, for how long and how often? Activity:Duration How many times per week: How did you hear about Enriched Health? Do you consent to participate in assessment and treatment procedures recommended by Enriched Health staff? Yes No Do you consent for Enriched Health to share medical information with other contacts and health care providers where relevant to your case? Yes No Cancellation Policy: Enriched Health has a 24 hour cancellation policy therefore if you need to cancel or reschedule your appointment you need to give 24 hours’ notice otherwise you will still be charged for your appointment. Please note rebates do not apply to missed appointments Do you agree to abide by this policy? Yes No Social Media Consent: Your case or information may be recorded and any recording or photograph(s) resulting from the recording, and any reproductions or adaptations of the written material, film and or photograph(s) can be used for all general purposes in relation to Enriched Health Care’s work including, without limitation, the right to use them for educational purposes, as well as for advertising, press releases and for use on the Enriched Health Care’s website and social media. I authorize Enriched Health Care to record by video, audio, still photographs or written correspondence. Yes No Have you had any cold or flu like symptoms? Yes No Have you done any overseas travel in the last three (3) months? Yes No Δ
