Patient Registration Form

PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth (DD/MM/YYYY) *

Gender

MaleFemaleNon Binary

Please specify how you heard about us or who referred you to us. *

PATIENT CONTACT DETAILS

Mobile Phone

Home Phone

Email

Address

Postcode

City / Suburb

State

Current Work Status

EmployedRetiredNot workingLight Duties

Occupation

EMERGENCY CONTACT DETAILS

Emergency Contact Name

Emergency Contact Number

Parent/Guardian Name - Under 16 (if different from above)

Parent/Guardian Contact Details

CURRENT INJURY & HEALTH INFORMATION

The following information will assist us to formulate the best treatment plan for yourself and ensure any treatment plan is completed safely. It will also ensure you get the most out of your initial consultation. All information will be kept in strict confidentiality

Please provide a brief description on what are you coming to see us about? *

Have you recieved treatment for this condition in the past. If YES, Please provide details.

YesNo

Have you had any imaging completed on this injury/condition? If Yes please provide details, including which Radiology Company conducted your scans: (E.g. MRI, X-Ray or Ultrasound @ South East Radiology Nowra)

YesNo

What would you like to achieve from your first consultation?

Are you suffering from any other conditions, injuries or pains that you think we may be able to assist you with during future consultations?

Please provide a brief description of your current level of exercise/physical activity

MEDICAL HISTORY

Medical History

Family Doctor/ Regular General Practitioner Name

Referring Doctor’s Name (if different to family doctor)

Do you have or have you ever suffered from any of the following:: *

Heart Condition (E.g. heart attack, defibrillator, heart surgery, Angina etc)StrokeFaint, Dizziness or loss of balance during phycial activity/exercise?Unexplained pains or discomfort in your chest at rest or during physical activity/exerciseAsthmaDiabetes (Type 1 or 2)Any other condition that may require special consideration for you to exercise?None of the above

If you answered yes, please provide additional information:

Please list any previous major surgeries or Injuries:

Please list any regular medications:

OTHER SERVICES

Are you interested in additional information on any of the following services offered at Astute:

Reformer PilatesStrength ClassesMixed Strength & Reformer Classes

Terms & Conditions

Cancellation: Any appointments or classes missed, cancelled or rescheduled within 24 hours will incur the full cost of the appointment or class. (Fee may be waived in some extenuating circumstances).
Late Arrival: If you arrive late to your session, but within your appointment time frame, you may still receive treatment for a reduced time.

CONSENT

I hereby grant Astute authorization to access pertinent imaging records to facilitate the administration of my care while at Astute. I understand that this information will be maintained with utmost privacy and confidentiality.

I consent to Astute contacting my medical practitioners and releasing relevant medical records for the purpose of managing my injury or condition.

I confirm that I have read, understand and agree to Astute's terms and conditions including the cancellation policy.
*

I consent to perfoming exercise under the guidance of Astute's therapist's and will have the opportunity to discuss my proposed care and any risks associated with performing the recommended exercise. *

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

Signature *

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Today's Date *

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