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Self-referral form

Please complete your details here for your self-referral.

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Personal information

Do you identify as Aboriginal and/or Torres Strait Islander?
Do you have a support person or carer?
Do you need a translator?
What are your current living arrangements?

If you have any questions regarding this form or need assistance in completing this form, please contact us on 5122 6015. Thank you!

Please note that we will be in contact with you to arrange an appointment within 2 to 3 working days of receiving your information.

Please complete your medical history below.



Medical history

Has your medical practitioner ever told you that you have a heart condition, or have you ever suffered a stroke?
Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
Do you ever feel faint, dizzy, or lose balance during physical activity/exercise?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
Do you have any other conditions that may require special consideration for you to exercise?

Have you experienced any of the following?

Bladder or bowel incontinence
Numbness in the groin/between your legs
Loss of sexual function
Sudden, unintentional weight loss (greater than 10% in the last 6 months, or 5% in the last month)
Unexplained night pain

Further information

Do you have a family history of heart disease? (stroke, heart attack, etc)
Do you currently smoke, or have you quit smoking in the last 6 months?
Have you ever had any form of cancer?
Have you been told that you have high blood pressure?
Have you been told that you have high cholesterol/blood lipids?
Do you have diabetes (T1 or T2?)
Do you have any respiratory disease?
Do you have any neurological conditions? (e.g. Parkinson’s, multiple sclerosis, nerve damage, peripheral neuropathy, etc)
Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise?
Have you spent time in hospital for any condition/illness/injury over the last 12 months? (including day admission)
Have you given birth within the last 12 months?
Have you had any falls in the past 12 months?
Do you use any walking aids?
Do you have any diagnosed mental health conditions?

Consent to seeking further information

In some cases, we may request further information from your GP or other healthcare providers to ensure we have all relevant health information to best support your care. Do you consent to us contacting your GP or other relevant professional for any information we may require related to your physiotherapy care?

Thank you for taking the time to complete this information. We will be in contact with you to arrange an appointment within 2 to 3 working days of receiving this information. Please be assured that all telehealth consultations are private, confidential and adhere to the same clinical standards as face-to-face consultations at your local health service.
You can find more information about your privacy here.