CONTACT INFORMATION HEALTH IS WHAT WE DO. we’re looking forward to working with you. <br> Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Mobile Phone Number *Date of Birth (Day/Month/Year) *NDIS Participant Number *Who Manages Your Plan *Self-ManagedPlan ManagerNDIAIf Plan Manager, please provide name of companyIf Plan Manager, please provide email address for invoicingEmergency Contact Name *Emergency Contact Number *Street Address *City *Post Code *Please list any medical conditionsPlease list any medications that may affect exercisePlease list any injuriesPlease list your health & wellness goals *"Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/Exercise? " *YesNoIf yes, please describe below:"If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?" *YesNoN/AIf yes, please describe below:"Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?" *YesNoN/AIf yes, please describe below: "Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?" *YesNoIf yes, please describe below: "Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?" *YesNoIf yes, please describe below: "Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?" *YesNoIf yes, please describe below: "Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise " *YesNoIf yes, please describe below: "Do you have a family history of heart disease?" *YesNoIf yes, please describe below:"Do you smoke cigarettes on a daily or weekly basis?" *YesNoN/AHave you quit smoking in the last 6 months? *YesNoN/A"Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity " *YesNoIf yes, please describe below: Have you been told you have high cholesterol? *YesNoIf yes, is it now controlled or under GP management?YesNoAre you pregnant or have you given birth within the last 12 months? *YesNoN/AIf yes, please let us know if you are pre- or post- natal and any specific exercise guidelines provided by your health practitioner and confirm you have been given clearance to undertake physical activityHave you been told that you have high blood sugar? *YesNoIf yes, is it now controlled or under GP management?YesNoHave you been told that you have high blood pressure? *YesNoIf yes, is it now controlled or under GP management?YesNoPlease let us know any further information regarding health / health conditions in more depth below:How did you hear about us? *FriendFamilyCar SignageStudio SignageGoogleReferralOther (please specify below)*Other - Let us know how you found out about usI confirm that all the information I have provided is true and correct *YesBy inserting my name below I confirm that I have read the T&Cs and Service Agreement (found below the form) and agree to terms of service *Submit View our T&C’s and Service Agreement Here