Healthy Habits
Wanting to know more about the Healthy Habits Program at Optimum Exercise Physiology??
Please fill out your details below, and we will contact you with more information.
Email address *
Name *
Email Address *
Telephone Number
I have one or more of the below conditions (Please tick all that apply) *
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I am interested in the following programs *
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Any other comments
Please answer the following questions and health screenig questions as this information is required to be included on your referral to the program.
Address
Do you associate as being Aboriginal or Torres Strait Islander *
Date of Birth *
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YYYY
Please tick the chronic condition or health risk factors which are relevant to you *
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What services are you interested in? *
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Pre exercise screening questions
Has your doctor every told you that you have a heart condition or have you suffered a stroke? *
Do you ever experience unexplained pains in your chest at rest or with physical activity/exercise? *
Do you ever feel faint or dizzy or lose your balance whilst undertaking exercise/physical activity? *
Have you had an asthma attack requiring immediate medical attention within the last 12 months? *
If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose levels in the last 3 months? Also Respond no if you don't have diabetes. *
Do you have any other conditions that may require special consideration for you to exercise? *
If yes, please provide short answer (ie sore back)
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This form was created inside of Optimum Exercise Physiology.