New Client Form

Please fill out the New Client Form before your consultation

✓ This will speed up the admin process before your Full Body Assessment, so we can get right into helping you

Personal Information

So that we can best be prepared for your full body assessment and go straight into working on your goals, please fill out the form below

*Are mandatory fields

First Name*	Surname*
Preferred Name	Gender
Address*	Suburb*
Date of Birth*	Occupation
Email*
Mobile Number*	Home Number
Emergency Contact	Emergency Contact Relation to you
Emergency contact's phone number

Best Communication Method

Appointment Reminders Method*		Best Communication Method to reach you?
Consent to receive emails from MD Health (including important information about your program)

Goals of your program: PLEASE FILL THIS OUT

What would you like us to help you with? What are your primary goals?

Medical Information

Please select all of the following that apply to you OR have applied in the past

Musculo-skeletal Information

Back Pain Back Pain	Neck Pain Neck Pain
Knee Pain Knee Pain	Shoulder Pain Shoulder Pain
Headaches Migraines Headaches/Migraines	Ankle Pain Ankle Pain

Long Term Musculo-skeletal Information

Ankylosing Spondylitis Ankylosing Spondylitis	Scoliosis Scoliosis
Spinal Surgery Spinal Surgery	Spinal Trauma or Fracture Spinal Trauma/Fracture
Osteoarthritis Osteoarthritis	Rheumatoid Arthritis Rheumatoid Arthritis

Long Term Health Information

Osteopenia Osteopenia	Osteoporosis Osteoporosis
Psoriasis Psoriasis	Thyroid Disorder Thyroid Disorder
Cancer Cancer	Fibromyalgia Fibromyalgia
Diabetes Diabetes	HIV or Hepatitis HIV/Hepatitis C
Asthma or Allergies Asthma/Allergies	Kidney Disease Kidney Disease
Chronic Fatigue Chronic Fatigue	Bone or Joint Infection Bone/Joint Infection

Cardiac and Vascular Health Information

Arrhythmias Arrhythmias	Heart Disease or Angina Heart Disease/Angina
High Blood Pressure High Blood Pressure	Chest Pain Chest Pain
Blood Clots Blood Clots	Aneurysm Aneurysm
High Cholesterol High Cholesterol	Stroke Stroke

Other Health Information

Depression Depression	Anxiety Anxiety
Other Mental Illness Other mental illness	Sudden Weight Loss Sudden Weight Loss
Sudden Weight Gain Sudden Weight Gain	Eating Disorder Eating Disorder
Unsteadiness/Dizziness Unsteadiness/Dizziness	Difficulty Walking Difficulty Walking
Neuropathy Neuropathy

Medical/Surgical Procedures

Please list post and scheduled surgery

Date	Procedure

Medications

Medication	Dose and freqency

GP and Specialists Details

We would like to contact your GP and/or Specialists if we see that there is a need.

By providing their details below, you agree that we can contact them if and when the need arises

GP's Names	GP's Practice details
Specialist's Names	Specialist's Practice details
Specialist's Names	Specialist's Practice details
Specialist's Names	Specialist's Practice details

Pregnancy Information

Only fill out if relevant

Are you pregnant?	Expected due date
Obstetrician Name	Hospital/Clinic

Pelvic Floor Questions

Fill out if relevant

Do you have bladder leakage when you exercise, cough, sneeze or laugh? Do you need to rush to the toilet and sometimes won't make it in time?

Do you have any problems with your bowels? Such as constipation, leakage or straining?

Do you have any pelvic pain or sexual health concerns?

Women Only: Do you ever experience a heaviness sensation or a bulge feeling in your vagina?

How did you find out about us?

Further Information

If there is any further information that you think is important, please type in the box below

Terms and Conditions:

Commitment

To get the most benefit from our Clinical Exercise & Pilates program, we recommend that you book and attend at least two Clinical Exercise & Pilates sessions per week for 13 weeks. There is no 13 week contract, but a commitment for you to complete your program in order to maximise the benefits of what our 13 week Clinical Exercise & Pilates program can do for you. If, at any point, you do not feel that you are responding as well as expected, please discuss this with a member of our clinical staff. If you no longer wish to attend or complete your program, we would appreciate your feedback.

Payment

All payments are invoiced at the time of your session. Your session fee will be debited from your nominated credit card or as per the payment preference you have indicated.

Cancellations

If you are unable to attend an appointment, at least 6 hours’ notice is required. This enables any clients on the waiting list to be scheduled.

Missed appointments or cancellations made within 6 hours of the scheduled appointment time will be charged at the full appointment price.

We understand that emergency situations can arise which prevent notice being given. We may, at our discretion, make allowances for these situations.

Management Rights

The management of MD Health reserve the right to cancel your Clinical Exercise & Pilates program if members are seen not to comply with MD Health’s Terms & Conditions. Our Physiotherapists will oversee your Clinical Exercise & Pilates program. Please let our practitioners know if you have any issues or conditions that may affect your session. This will allow us to alter your program accordingly.

Mobile Phones

Out of respect for other clients, please turn off or put your mobile phone on silent while you are at MD Health. Our clinicians do not take calls during sessions, unless it is an emergency.

Terms & Conditions

Please check the box below to acknowledge that you have read and agree to our Terms and Conditions. If you have any questions, please speak to a member of our Reception staff.

I agree with the terms and conditions at MD Health* I agree with the terms and conditions at MD Health*