Pain Codex One-Off Consult

[PC] One-Off Consult Pre-Screening

Pain Codex One-Off Consult: Medical Pre-Screening

Please answer the following questions to the best of your ability so we can ensure you are safe to exercise and participate in Exercise Physiology services provided by Resilience Rehab & Performance Pty Ltd.

30 Questions

What Is Your Name?*

First Name

Last Name

Enter Your Best Email and Phone*

Mobile Number

Date of birth*

Date of birth

Gender*

Gender

Male

Female

Other

Describe the problem/s you are looking for help with?*

What are you having the most trouble with and how is it impacting you?

Describe the problem/s you are looking for help with?

How long have you been experiencing the problem/s?*

How long have you been experiencing the problem/s?

Please list any current or previous muscle, bone, tendon, ligament or joint problems.*

As much detail as possible.

Please list any current or previous muscle, bone, tendon, ligament or joint problems.

Please outline any past medical history.*

Allergies or any other underlying conditions

Please outline any past medical history.

Do you currently have or have had any of the following before?*

Do you currently have or have had any of the following before?

Bladder dysfunction

Cancer

Immunosuppression

Night pain

Recent physical trauma

Loss of sensation to the area of the buttocks, perineum (area between penis/vagina and anus) and/or inner surfaces of the thighs?

Lower body neurological deficit (numbness or inability to use limbs)

None of the above

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

Maybe

Do you have a family history of heart disease?*

Including but not limited to; high blood pressure, stroke, heart failure, heart attack?

Do you have a family history of heart disease?

Yes

Maybe

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

Yes

Maybe

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

Yes

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?*

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

Yes

Do you have any other conditions that may require special consideration for you to exercise?*

Do you have any other conditions that may require special consideration for you to exercise?

Yes

Maybe

Are you currently taking prescribed medication(s)?*

If yes, please list with schedule and amounts.

Are you currently taking prescribed medication(s)?

Do you drink alcohol?*

If yes, please outline on average how many drinks per week.

Do you drink alcohol?

Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?*

Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?

Yes

Have you been told you have high blood pressure?*

Have you been told you have high blood pressure?

Yes

Are you pregnant or have you given birth within the last 12 months?*

Are you pregnant or have you given birth within the last 12 months?

Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?*

If yes, please list with as much detail as possible.

Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?

Describe your current physical activity/exercise levels in a typical week.*

Describe your current physical activity/exercise levels in a typical week.

Little to none

Very light, but consistently

Moderate to hard, consistently

5-7 days per week, very hard

Please describe your current training here in-depth.*

Current program including day splits/exercises, cardio, walking etc

Please describe your current training here in-depth.

Have you recently changed or increase your training/exercise load?*

If yes, please elaborate.

Have you recently changed or increase your training/exercise load?

Please list all of the equipment you currently have access to.*

If full gym, just type that. If you train at home, please list everything you have.

Please list all of the equipment you currently have access to.

Consent*

By ticking this box I acknowledge I answered the previous questions honestly and to the best of my ability.

I also acknowledge that I understand the risks associated with exercise (the benefits of physical activity far outweigh the possible associated risks in most individuals.

However, I recognise that, despite all precautions on the part of Resilience Rehab & Performance Pty Ltd, there are risks of injury or illness including but not limited to certain acute physiological changes and musculoskeletal injury: muscular strains, joint sprains, delayed muscle soreness, abnormal blood pressure, fainting, disturbances of heart rhythm, and in very rare instances heart attack and stroke.)

Finally, I agree if the health history, physical activity readiness questionnaire or evaluation indicates that I should see my physician before exercising, I will do so.

Consent

Yes

Signature*

Signature