Motion Mend

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Your Role ParentSupport PersonLAC/Support CoordinatorPlan ManagerOther First Name Last Name Phone No. Email Postcode Tell us more About you

Participant

Participant Details

First Name Last Name Preferred Name Preferred Pronoun Date of Birth Suburb State Postcode Reason for Referral

How would you /participant prefer to receive our services? TelehealthFace-to-faceEither Which services are you / participant interested in? NDIS ServicesExercise Prescription and ProgrammingInjury, Pre and Post-op RehabilitationChronic Disease ManagementSports Performance EnhancementFunctional Movement ScreeningGroup Exercise ClassesWeight LossGP Care PlansTherapy OptionsNot sure

Do you currently have an NDIS plan? YesNo

NDIS Participant Number Plan Start Date Plan End Date

How will Funds be Claimed? * Agency ManagedPlan ManagedSelf-Managed

Plan Manager Name Plan Manager Company Plan Manager Phone Plan Manager Email

Do you have a support coordinator? If yes, please provide their contact details. YesNo

Enter Name Enter Email Enter Phone No.

Are there any specific goals or objectives outlined in your NDIS plan related to exercise or rehabilitation?

What are your primary fitness goals or reasons for seeking exercise programming? Do you have any specific medical conditions or limitations that should be considered in designing your exercise program? Have you had any previous experience with structured exercise programs or personal training? Are there any activities or exercises that you particularly enjoy or dislike? What is your typical weekly schedule like in terms of available time for exercise?

Please describe your injury or surgical procedure in detail. What is the status of your rehabilitation process? Have you undergone any previous rehabilitation programs for this injury/surgery? Are there any specific recommendations or restrictions provided by your healthcare provider regarding your rehabilitation? Do you have any imaging reports or medical records related to your injury/surgery that you can provide?

Please list any chronic medical conditions you have been diagnosed with. Are you currently taking any medications for these conditions? Have you undergone any recent medical tests or assessments related to your chronic conditions? Are there any specific symptoms or challenges you are facing due to your chronic conditions that you would like to address through exercise or lifestyle changes? Have you received any recommendations from your healthcare provider regarding exercise or physical activity?

What specific sport or physical activity are you seeking performance enhancement for? What are your current training habits and routines? Do you have any upcoming competitions or events that you are preparing for? Are there any areas of your performance that you feel need improvement? Have you worked with a sports coach or trainer in the past?

Have you had any previous movement assessments or screenings? Are you currently experiencing any pain or discomfort during specific movements? Are there any activities or movements that you find challenging or uncomfortable? Have you recently experienced any injuries or accidents that may impact your movement patterns? Are you currently participating in any physical therapy or rehabilitation programs?

Are you interested in specific types of group exercise classes (e.g., cardio, strength training, flexibility)? Have you participated in group exercise classes before? What is your preferred level of intensity for group workouts? Do you have any specific health concerns or limitations that should be considered in group exercise settings? Are there any scheduling constraints or preferences for attending group classes?

What are your primary motivations or goals for weight loss? Have you attempted weight loss programs or diets in the past? Are there any medical conditions or medications that may affect your weight loss journey? Do you have any specific dietary preferences or restrictions? Are you open to incorporating both exercise and dietary changes into your weight loss plan? (May include referral to allied health e.g., qualified nutritionist)

Have you been referred by your GP for a specific care plan? Referring doctor What are the main objectives or goals outlined in your GP care plan? Are there any exercises or activities recommended by your GP that we should be aware of? Have you had any recent consultations or updates with your GP regarding your care plan? Are there any other healthcare providers involved in your care plan that we should coordinate with?

Have you received therapy treatments like reformer Pilates or dry needling before? What specific areas or conditions are you seeking therapy for? Do you have any concerns or hesitations about these therapy options? Are you currently experiencing any pain or discomfort that you hope therapy sessions can address? Do you have any medical conditions or contraindications that we should be aware of before starting therapy sessions?

Are you covered by any private health fund? If so, which one? Do you have your Medicare number available? Any Relevant Attachments or Files. How often would you like to see us ideally? Weekly / twice weeklyFortnightlyMonthlyOne off or less than monthlyUnknown

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Enter Name Gender Email Phone Suburb State Postcode Primary Disability Other relevant health information Is there a Guardian involved? YesNo

Enter Name Phone Email

Is there a Support Coordinator involved? YesNo

Enter Name Phone Email Company

Who is the Plan Nominee or Child Representative? MeOther

Enter Name Phone Email Relationship to Participant Will an Interpreter be Needed? YesNo

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