PEM Client's Details Form

Personal Details

Title

Gender *

First Name *

Last Name *

Date of Birth *

Email *

Mobile Phone (SMS Reminders) *

Home Phone

Work Phone

Home Address *

City *

State *

Postcode *

Family Doctor *

Emergency Contact Person *

Preferred Phone *

How would you like to receive appointment reminders? *

Would you like to receive our monthly Healthy News email? *

Yes Healthy News UpdatesNo Healthy News Updates

Medical Screening Questions

Has your doctor said you have heart problems? *

YesNo

Do you have high blood pressure? *

YesNo

Do you have faints, funny turns or dizziness? *

YesNo

Do you have epilepsy? *

YesNo

Do you consume regular prescribed medication? *

YesNo

Do you have panic attacks? *

YesNo

Do you have asthma? *

YesNo

Do you have diabetes? *

YesNo

Do you have a bleeding disorder? *

YesNo

Do you have an autoimmune disease? *

YesNo

Please described *

Has a doctor ever told you that you have a bone or joint problem that maybe aggravated by exercise? *

YesNo

Is there a good reason not mentioned here why you should not follow an activity program even if you wanted to? *

YesNo

Have you had any surgery in past 6 weeks? *

YesNo

Are you pregnant? *

YesNo

How many weeks are you? *

If you are taking any regular medication, what is it and what is it for?

Privacy Considerations

The privacy act requires medical service providers to obtain consent from their patients to collect, use and disclose personal information. The information contained on this form and the information gained from this assessment and its associated documents maybe be exchanged between the examining therapist, medical officer, and referrers.

I provide my consent for Esperance Physiotherapy to collect, use and disclose my personal/medical information for the purpose of assessing my medical fitness in relation to the nominated position.

Privacy Signature *

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Pre Assessment Conditions

I will not eat, smoke, or drink tea or coffee for at least 2 hours before the fitness test.
I am not recovering from illness, a cold, or am taking beta-blocker drugs which will depress heart rate scores or influence test performance.
I will wear loose-fitting comfortable clothing and appropriate footwear.
I will not undertake any heavy physical exercise for 24 hours before the fitness test.

This assessment is designed to test your functional capacity. You are expected to set your own limits. You may stop the assessment at any stage and the assessor will stop the assessment if they are of the opinion you are either unable or unsafe to proceed.

I confirm that none of the above pre-test conditions applies to me, and that I am fit and able to complete my Pre-Employment Fitness assessment today.

Pre Assessment Signature *

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Client Declaration

I hereby declare that my medical and pre-test condition statements are true and correct to the best of my knowledge.

Client Declaration Signature *

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