COORDINATED FITNESS PATIENT INTAKE FORM

General Information

First name *

Surname *

Date of birth *

Email Address

Home phone

Mobile phone

Street Address *

Suburb *

State *

Postcode *

How did you find out about us? *

Medicare Number

Reference Number

Medicare Expiry Date

Client Representative Details (If Applicable)

Full Name

Contact number

Email

Emergency Contact Information

Emergency contact *

Phone *

Emergency contact’s relationship to you

Treatment Goals

What would you like us to assist you with today? *

What is your one main goal in the next 90 days? *

Why is it important to you that you achieve this goal? *

What treatment have you had in the past? Did you have success or not with this treatment? *

Medical Information

Please list any medications you are currently taking

If it is easier upload a photo of your medications

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Please write your medications here if you have not uploaded a photoPlease list all current medications (incl. dose and reason)

Do you need any quick medication assistance E.g EpiPen, Angina Spray, Ventolin *

YesNo

If Yes, please specify

Have you had any surgeries especially in the last 12month? *

YesNo

If Yes, please explain

Health Conditions

Please list any other condition you may have that have not been previously mentioned:

Do you smoke?

YesNoI used to smoke

Please upload any important documents / referrals you may have which are of benefit for your appointment

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NDIS DETAILS (If Applicable)

Plan

Plan ManagedSelf ManagedAgency managed

Funding for services category

IDLHWBCore

If Plan Manged Name of Organisation

Email for invoices to be sent

NDIS Number

NDIS Goals

Plan Start Date

Plan End Date

Support Coordinator Name

Support Coordinator Email

Support Coordinator Phone Number

Clinic
Home

Reason for referral

Exercise Physiology gym based programExercise Physiology hydrotherapy programExercise Physiology home program

Cancellation Policy

If you are unable to attend the scheduled appointment time for any reason, please contact Coordinated Fitness on 0417 765 818 or admin@coordinatedfitness.com and inform our team as soon as possible.

You will receive a text reminder for your individual or group session 9am 2 days before yourappointment. This gives you time to reschedule if needed.

All missed appointments and cancellations made within 24 hrs of a scheduled appointment will result in a cancellation fee of the full session.

Your Exercise Physiologist will provide you with the recommended action plan, so you gain the best health outcomes. You attending your planned sessions is part of you reaching your health goals. We have a waitlist of people trying to attend one on one or group sessions. When sessions are cancelled last minute or you do not attend it does not give us the opportunity to offer your session to another Coordinated Fitness Community member.

When a session is cancelled within 24hrs or you do not show up to your appointment the full fee will apply to the missed session.

Consent

I agree to the terms of the cancellation and non-attendance fee. *

I confirm that above information I have provided is true, complete and accurate. *

Signature

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Date