First Name*Surname*DOB*AddressSuburbPostcodeMobile*WorkMarital StatusSingleMarriedDe factoWidowDivorcedEmail*OccupationSexMaleFemaleHow did you hear about us?Walked pastGoogleVoucherYellow PagesWord of MouthOtherIf Word of Mouth or Other, please indicate who or where. If you found us through a Google search, please indicate the keywords you typed into the search box. e.g. Exercise Physiology North SydneyYour ProblemMajor Complaint*Date of onsetPrevious treatmentOther complaintsPrivate health insuranceYesNoMedicareYesNoWorkcover / CTP claim?YesNoClaim noDept of Veteran's AffairsYesNoGP or Medical Practice detailsExercise History Does your occupation involve sitting for a large part of the day?YesNoDo you have current activity patterns?YesNoIf yes, what type of activity?Minutes per sessionSessions per week?Intensity?EasyModerateHardOtherHow many years have you been a regular exercise?Has your activity levels changed over the last 5 yearsYesNoAre you experiencing pain during exercise?YesNoIf yes, does it stop you from exercising?YesNoYour Medical History Have you ever had any of the following disease?DiabetesPeripheral Vascular DiseaseOsteoporosisHigh Blood PressureAnemiaEmotional DisordersStrokePhlebis or EmboliEasting DisordersPulmonary DiseaseCancerOtherIf other, please specifyIf you could improve anything about your health, what would be your goals?1:2:3:Exercise Risk FactorsDo you often have pains in your heart and chest, especially with exercise?YesNoHave you, at any time in the last 12 months, had an attack of shortness of breath that came on during the day when you were not doing anything strenuous?YesNoDo you often feel faint or have spells of severe dizziness, particularly with exercise?YesNoHave you, had an attack of shortness of breath that came on after you stopped exercising, at anytime in the last 12 months?YesNoHave you at any time in the last 12 months been woken at night by an attack of shortness of breath?YesNoDo you experience swelling or accumulation of fluid about the ankles?YesNoDo you often get the feeling that your heart is beating faster, racing or skipping beats either at rest or during exercise?YesNoDo you regularly get pains in your calves and lower legs during exercise, which are not due to soreness or stiffness?YesNoDo you often experience fatigue when you are not doing anything strenuous, or when you are not doing anything at all?YesNoCardiac Risk FactorsDo you smoke cigarettes daily?YesNoIf no, have you quit smoking in the last 2 years?YesNoIf yes, how many cigarettes do you smoke each day on average?YesNoDo you have a close relative (i.e. Father, mother, brother or sister) who has had a stroke, heart attack or other cardiovascular disease?YesNoIf yes, what relation was this person (e.g. father, sister)YesNoAt what age did he or she suffer a stroke/heart attack?YesNoDid your relative die suddenly as a result of a stroke or heart attack?YesNoHas your doctor ever told you that you have high blood pressure?YesNoBack Pain or Injury PatientPresentation of back pain at age <20 years or onset >55 yearsYesNoViolent trauma, eg. fall from a height, motor vehicle accidentYesNoConstant pain that worsens over a day regardless of your activity and is not relieved with postural changeYesNoThoracic painYesNoPrevious history of cancer, steroid use, drug abuse, HIVYesNoSystematically unwell, e.g. significant weight lossYesNoPersistent severe restriction of trunk bendingYesNoWidespread neurologic changes e.g. unsteady gait, altered sensation in the legs or arms, bladder/bowel problemsYesNoPlease read the following information and tick the box if you have read and understand the statement.Explanation of tests: You will perform a number of tests specific to your injury/conditon. This may include efforts such as bending forward, pulling, lifting, walking and stair climbing. The assessment will stop if you show signs of intolerance. You are free to terminate the assessment at any time.Explanation of tests: You will perform a number of tests specific to your injury/conditon. This may include efforts such as bending forward, pulling, lifting, walking and stair climbing. The assessment will stop if you show signs of intolerance. You are free to terminate the assessment at any time.Benefits to be expected: The results of the assessment will be used to determine your suitability to undertake active treatment and to decide on the best type of treatment.Freedom of consent: Your permission to perform this assessment is voluntary. You are free to stop the test at any point if you so desire.Inquiries: Any questions about the procedures used in the assessment or the results of your test are encouraged. If you have any concerns or problems, please ask the Exercise Physiologist for further explanations.Informed Consent: I have read this form and have had the assessment procedures explained to me. I have had the opportunity to ask questions that have been answered to my satisfaction. I consent to participate in the assessment. I also give permission for North Sydney Sports and Chiropractic to disclose details of my pre‐assessment medical screen questionnaire and the results of the assessment and my treatment with the treating parties.
