Exercise Physiologist Paperwork

Name

This field is for validation purposes and should be left unchanged.

Who are you completing this paperwork for?(Required)

Is this your first visit to an Exercise Physiologist at NIPM?(Required)

Yes

No

If you have seen the exercise physiologist in the last 12 months, you do not have to complete the patient demographic paperwork again.

Please follow the link to complete your psychometric data only if you are a CTP/WC patient.

Exercise Physiology treatment defined:

Exercise Physiology treatment involves the individualised interventions to assist with management and/or prevention of chronic disease and other pre-diagnosed conditions. In order to allow safe and accurate prescription, you will be required to complete an Initial Exercise Physiology Assessment. You may also be required to complete a range of physical capacity assessments to assess cardiorespiratory fitness and /or muscular strength and endurance.

Responsibilities of the participant:

Prompt full disclosure of your current health status in addition to any current or previous experience of adverse signs or symptoms with exercise is important in ensuring your safety during participation of Exercise Physiology treatment. This disclosure extends throughout the intervention in the case where any new diagnosis is made or changes to your current health issues occur. If identified as necessary by your treating Exercise Physiologist, medical clearance may be required from your GP prior to participation in an individualised program.

Once an individualised intervention has been established, it is important that you complete only the interventions prescribed. If you are interested in trialling an alternative intervention to that prescribed, it is important that you consult your Exercise Physiologist to ensure its suitability.

Benefits to be expected:

Your participation in an Initial Exercise Physiology Assessment will help to ensure that an individualised intervention is prescribed relevant to your current ability. Potential gains from participating in an intervention program include but are not limited to: management of pain, improvements in functional work and ADL tolerances, weight management, and management of chronic diseases.

Enquiries:

Any questions about the procedures used or results gained from your physical capacity assessment are encouraged. If you have any questions or concerns at any stage throughout your treatment, please ask for further explanation.

I have read and understood the above statements and understand what is required of me with regards to exercise physiology.(Required)

Yes, I understand and I voluntarily agree to participate in a physical capacity assessment (if required) and exercise program. I understand that I am able to withdraw from participation at any time by notifying my treating Exercise Physiologist.

No, I do not understand and would like to discuss further.

Your Medical Providers

Were you referred by a GP or a Specialist?(Required)

GP referrals are valid for 12 months. Specialist referrals are valid for 3 months.

Specialist

GP Referral

No referral (I understand there will be no rebate)

Who is your referring Doctor?(Required)

Referring Doctors address(Required)

City or Suburb State

Who is your regular GP?

GPs Address

City or Suburb State