Let’s get you started with our Health and Wellness Check Please take a few minutes to complete the form below so we can best understand your needs. Name(Required) First Last Date of Birth(Required) DD slash MM slash YYYY Phone(Required)Email What is/are your underlying medical diagnosis or health condition/s?(Required)What is your overall reason for your visit?(Required)What would you like to achieve in your first visit?(Required)What are your current NDIS/NIISQ goals as per your plan? (If applicable)General MedicalDo you have a history of heart and/or lung conditions? if so, please provide detail.Do you have a history of neurological conditions? If so, please provide detail.Have you had any recent hospital admissions? If so, please provide detail.Do you have a history of any surgeries in the past 12 months? If so, please provide detail.Please list your medications:Health and WellnessDo you have a history of smoking, drinking and/or substance abuse? If so, please provide detail.Are you currently experiencing any pain that limits your function? If so, please provide detail.Are you currently participating in regular physical activity, rehab, or exercise? If so, please provide detail.Do you have difficulty with completing daily activities (eg. self-care, getting around)? If so, please provide detail.Have you had any falls in the past six months? If so, please provide detail.Additional InformationPlease provide any other relevant information you feel is important.How did you hear about the Healthy Living Centre?(Required) I am a client or member of Spinal Life Australia Spinal Life website Google search Social media Event or conference Friend or family member GP or other health professional Other ConsentConsent(Required) To the best of my knowledge, I have completed this General Health and Wellness Screen correctly and have stated any medical conditions which may restrict my ability to safely participate in activities at the Spinal Life Healthy Living Centre. By signing this document, I confirm that I have read and agree to the terms and conditions provided to me.Signature(Required)
