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Healthy Habits
Wanting to know more about the Healthy Habits Program at Optimum Exercise Physiology??
Please fill out your details below, and we will contact you with more information.
* Indicates required question
Email
*
Your email
Name
*
Your answer
Email Address
*
Your answer
Telephone Number
Your answer
I have one or more of the below conditions (Please tick all that apply)
*
Diabetes
High Blood Pressure
Overweight/Obese
Kidney Disease
High Cholesterol
Osteoarthritis
Poor nutrition
Heart Disease
Low Physical Activity Levels
Depression and/or anxiety
Required
I am interested in the following programs
*
Individual support from an Exercise Physiologist
Group Exercise Programs & Education
Required
Any other comments
Your answer
Please answer the following questions and health screenig questions as this information is required to be included on your referral to the program.
Address
Your answer
Do you associate as being Aboriginal or Torres Strait Islander
*
Yes
No
Date of Birth
*
MM
/
DD
/
YYYY
Please tick the chronic condition or health risk factors which are relevant to you
*
Diabetes
Heart Disease
HIgh body weight
High Cholesterol
Low Physical Activity Levels
Poor nutrition
High Blood Pressure
Kidney Disease
Osteoarthritis
Cancer
Other:
Required
What services are you interested in?
*
Group Exercise & Education
Individual Exercise sessions
Required
Pre exercise screening questions
Has your doctor every told you that you have a heart condition or have you suffered a stroke?
*
Yes
No
Do you ever experience unexplained pains in your chest at rest or with physical activity/exercise?
*
Yes
No
Do you ever feel faint or dizzy or lose your balance whilst undertaking exercise/physical activity?
*
Yes
No
Have you had an asthma attack requiring immediate medical attention within the last 12 months?
*
Yes
No
If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose levels in the last 3 months? Also Respond no if you don't have diabetes.
*
Yes
No
Do you have any other conditions that may require special consideration for you to exercise?
*
Yes
No
If yes, please provide short answer (ie sore back)
Your answer
Send me a copy of my responses.
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