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First name

Last name

Email

Phone

I agree to be contacted by phone and email.

Please tick any of the condtions you have:

Abdominal/ Digestive problems

Allergies

Arthritis

Asthma or lung conditions

Blood clots

Cancer / Tumors

Chronic Fatigue

Chronic pain

Depression

Diabetes

Fatigue

Fibromyalgia

Headaches or migraines

Hearing problems

Heart, circulatory problems

Hernias

High / Low blood pressure

Infectious disease

Lymph node removal

Motor vehicle accident / trauma

Muscle or joint pain

Muscle, bone injuries

Numbness or tingling

Phlebitis

Pregnancy

Rash, athletes foot/tinea

Seizures

Skin disorders

Stroke

Varicose veins

Vision problems/contact lenses

Other

None

Other conditions not listed above:

Current medications (including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies):

Recent surgeries and dates of surgery

Current symptoms: (location and duration or onset)

History of presenting complaint: (how it happened - position / direction etc)

Behaviour of and type of pain: (constant / with movement / with activity / sharp / shooting / dull / aching etc)

Aggravating factors: (activities / posture / stressors)

Relieving factors: (movement/rest/posture/heat/cold)

Previous Treatments: (include all health care types – Complementary Medicine Practitioner and / or Medical Doctor, Physiotherapist, Osteopath, Chiropractor, Dentist):

Results:

Goals for my session:

I am fit and healthy and able to participate in this functional exercise session and will notify the trainer if my health history changes.

I agree to for the therapist to use Heidi Help - a note transcribing AI.

I agree to the terms & conditions and give consent for the training session.

Signature

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