Pre-Exercise Class Form

Email *

Would you like to receive our Thrive Health Monthly Newsletter, full of news, events, health tips and more? (you can unsubscribe at any time) *

Yes
No

Name *

First

Last

Preferred Name

Address *

Date of Birth *

Mobile Phone Number *

Private Health Fund? *

Emergency Contact (Name, Relationship, Phone) *

Regular GP (Name + Clinic)

How Did You Hear About Thrive Health Co. *

Please specify who referred you so we can thank them?

Do you currently exercise? *

Yes
No

If yes, please give details; type of exercise and frequency?

What do you hope to achieve from attending Thrive Classes? *

Are you currently taking any prescribed medication(s)? *

Yes
No

If yes, please explain medication(s) and doses?

Are you currently being treated for any injuries or conditions? *

Yes
No

If yes, please explain injuries or conditions?

Do you currently have any undiagnosed pain? *

Yes
No

If yes, please explain?

Pre-Exercise Screening - Please check any symptoms that you are experiencing or have experienced? *

Has your doctor ever 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 during physical activity/exercise?
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
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?
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Do you know of any other reason why you should not do physical activity?
None of the above

If you answered YES to any of the above symptoms, have you acquired guidance from your GP or appropriate Allied Health Professional prior to undertaking physical activity / exercise?

Yes
No

Please indicate any of the following that relate to you. *

Are you pregnant? *

Yes
No
Unsure

If answered yes to the above, have you obtained a letter of clearance from your GP/Obstetrician?

If pregnant, please outline what trimester you are in, number of weeks along?

Have you recently given birth? If yes, how many weeks postpartum are you?

Please describe the birth or any abdominal separation or other information you feel your instructor needs to be aware of?

Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months? *

Yes
No

If you are currently smoking, how many cigarettes per day or week?

Thrive Health Co. Care Agreement and Policy *

By ticking this box I consent and understand the information outlined in this agreement and policy as outlined below. And that the information I have provided is true, accurate and to the best of my knowledge.

I confirm the information I have provided in this form is accurate. I acknowledge the risks involved when participating in exercise for treatment of my physical condition and/or for achievement of my personal health and fitness goals. I have gained appropriate advice from my Doctor (if necessary) and I confirm that I am safe to partake in exercise. I will inform my treating practitioner of any previous or pre-existing medical conditions that may affect my ability to exercise. I will inform my treating practitioner of any medication that I am currently administering to ensure safe and sustainable exercise is prescribed. I understand my treating Practitioner may take my blood pressure and/or heart rate prior to, during and/or after exercise to ensure exercise is regulated within desired limits.

I understand an initial assessment will be conducted at my first appointment to confirm my current health status with subsequent reviews to be performed at regular intervals to assess my progress. I have been informed and give consent for my Practitioner to contact my other Health Professionals including GP and/or Allied Health to report progress and ensure a holistic and informed treatment plan is developed.

I understand participating in this exercise program may improve my movement quality, and pain free range of motion as well as improve my cardiovascular fitness and everyday functioning.

I understand that I may experience some degree of discomfort during some of the exercises, particularly in the form of breathlessness and a feeling of fatigue in the legs or arms but the exercises will generally be within the my normal range of physical activity. I will decrease or stop exercise if I note abnormal discomfort and will report this to my treating practitioner immediately.

I understand I will be exercising in a clinic with gym equipment and I will ensure to take care when moving around the facility. In the event of an injury my Practitioner will ensure appropriate First Aid care is administered and appropriate medical treatment is made available.

It is my understanding and I have been informed that there exists the remote possibility during exercise of adverse changes including, but not limited to, abnormal blood pressure, fainting, dizziness, disorders of heart rhythm, and in very rare instances heart attack, stroke, or even death. I further understand and I have been informed that there exists the risk of bodily injury including, but not limited to, injuries to the muscles, ligaments, tendons, and joints of the body. Every effort, I have been told, will be made to minimise these occurrences by assessment of my condition prior to exercise, supervision during exercise and by my own careful control of exercise efforts. I fully understand the risks associated with exercise, including the risk of bodily injury, heart attack, stroke or even death, but knowing these risks, it is my desire to participate as herein indicated.

I understand that exercise will be completed under the supervision of my Practitioner when at the Clinic in a one on one, or in a group based setting depending on my personal preference and recommended therapeutic requirements. I understand my Practitioner may also prescribe me home exercises to independently perform. I adhere to the precautions outlined by my Practitioner to ensure exercises are performed safely.

OUR CANCELLATION POLICY

Thrive Health Co provides allocated appointment times to ensure the provision of essential and high quality care at all times. Therefore, for non-attendance, cancellations or change of appointment day without notice of at least 12 business hours, you will incur a cancellation fee of the 50% of our standard price. Any cancellations provided at least 12 business hours prior to your appointment time, will be at no charge.

If we receive advanced notice that you are unable to attend, other clients who may require an appointment with a therapist may be able to be seen in your time slot. Please be considerate of other people who may be requiring an appointment and are unable to get in with a therapist in a timely manner or at a time that suits them.

OUR PAYMENT POLICY
I accept financial responsibility for my consultations and treatment. Fees are due at the time of visit unless arranged, and agreed upon, in advance. Unauthorised late payments will attract administration fees, details of which are available on request.

Referrals Appreciated - as we are a family owned and operated practice – the majority of our patients come via the kind referrals from our current patients – just like you – this reduces our need to waste money on expensive advertising and concentrate on what we do best – helping as many people as possible. We thank you in advance for your kind referrals and support.

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