Initial Consult

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Initial Consult

iFitness

Health Assessment

PATIENT INFORMATION
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region Post Code
Date of Birth
Email
Occupation
Health Fund
Are you of Aboriginal or Torres Strait Islander Decent?
- YES
- NO
Who is your Doctor?
GP Name Practice
What is your reason for contacting iFitness?
MEDICAL CONDITIONS
Do you have any of the following:
- High blood pressure
- High Cholesterol
- Cancer
- Heart Attack
- Diabetes
- Epilepsy
- Chest Pain
- Heart Disease
- Stroke
- Kidney Disease
- Blood Clots
- Osteoporosis
- Respiratory Disease
- Arthritis
- Heart Failure
- Other
Please give details:
Do you have a family history of any of the conditions listed above?
- YES
- NO
Please give details:
HISTORY OF SYMPTOMS
Have you ever experienced any of the following?
- Discomfort (eg. Burning, pressure, pain, tightness, numbness) in chest, jaw, neck, back, or arms
- Light Headedness, Dizziness, Fainting
- Temporary loss of vision or speech (including blurry vision)
- Weakness or numbness in one side of the body Unusual shortness of Breath
- Rapid heart beats or palpitations Swelling in the ankles or other joints
Are any of your symptoms brought on or aggravated by physical activity, temperature, stress, eating or other factor?
- YES
- NO
Please give details:
Are you currently taking any regular medications?
- YES
- NO
Please give details:
Are you currently a smoker?
- YES
- NO
Are you, or have you been pregnant in the last 12 months?
- YES
- NO
In the last 12 months have you had any illness or surgery or been hospitalized?
- YES
- NO
Please give details:
Do you have any bone, muscle or joint problems?
- YES
- NO
Please give details of the treatment you received:
Please list any physical activity you do:
Is there any other relevant medical condition or information not covered by the above questions that you feel may limit your ability to participate in physical activity and exercise testing?
- YES
- NO
Please give details:

Initial Consult

iFitness

PATIENT INFORMATION

MEDICAL CONDITIONS

HISTORY OF SYMPTOMS