Patient Contact DetailsPatient Information FormStep 1 of 714%TitleMissMsMrsMrDrName* First Last Sex Male FemaleDOB*Address*Suburb/State*Post Code*Phone*Email* OccupationHow did you hear about In Balance?*GP referralInternet searchConsultant/SurgeonSporting club/TrainerPhysio referralFamily/FriendOtherName of referrer (if applicable)Reason for your appointmentDo you have a GP/Specialist referral? Yes NoReferring Doctors name*Referring Doctors addressWould you like your GP sent information regarding your injury and treatment Yes NoDoctors name:Doctors address:Do you have Private Health Cover? Yes NoName of FundAre you covered by Veterans Affairs? Yes NoIs this a Workers Comp claim? Yes NoInsurer and claim numberIs this a third party claim? Yes NoInsurer and claim numberIs this an Extended Primary Care Claim? (EPC) Yes NoTerms and Conditions: Payment is required at time of consultation. I understand that I will be personally responsible for all fees on my account. A cancellation fee may apply if I do not give sufficient notice of 24 hours or more. I accept the above terms and agree to abide by them* Agree DisagreeHow often do you exercise?NeverLess than once per week2 - 4 times per weekMore than 4 times per weekWhat type of exercise do you do?Do you have a cardiac pacemaker or metal implant?* Yes NoDetailsHave you had a stroke?* Yes NoDetailsDo you have heart problems?* Yes NoDetailsDo you suffer from high/low blood pressure?* Yes NoDetailsDo you have Diabetes?* Yes NoDetailsDo you have asthma or breathing difficulties?* Yes NoDetailsDo you have or have you had Cancer or a tumor?* Yes NoDetailsDo you suffer from Arthristis, Rheumatism or other point problems?* Yes NoDetailsHave you lost/gained weight in the past 6 months?* Yes NoDetailsHave you ever been seriously ill or had a major operation?* Yes NoDetailsDo you have any communicable disease (e.g. Hepatitis A,B,C,HIV/AIDS)* Yes NoDetailsDoes any health problem restrict your activities of daily living?* Yes NoDetailsAre you a current or ex-smoker?* Yes NoCurrent/past cigarettes per dayDo you consume alcohol?* Yes NoAlcoholic drinks per day/per week:Are you currently taking any prescription medication?* Yes NoType:Are you currently taking any non-prescription medication?* Yes NoType:Are you pregnant or trying?* Yes NoDetailsDo you experience chest pains?* Yes NoDetailsHave you had episodes of shortness of breath?* Yes NoDetailsHave you had episodes of severe dizziness?* Yes NoDetailsDo you experience difficulty breathing?* Yes NoDetailsDo you experience swelling around your ankles?* Yes NoDetailsHave you ever had heart palpitations?* Yes NoDetailsDo you regularly get muscle aches in your legs when walking?* Yes NoDetailsHas your doctor told you that you have a heart murmur?* Yes NoDetailsDo you know of any reason why you should not engage in physical activity?* Yes NoDetailsNext of kin:* First Last Phone numberΔ