Healthy Habits - Falls Prevention Group
Would you like to join a falls prevention group program at no cost to you??
Please fill out your details below, and we will contact you with more information.
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Email *
Name *
Telephone Number *
Date of Birth *
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Address *
Do you identify as Aboriginal or Torres Strait Islander
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Do you have any of the following conditions? *
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What services are you interested in? *
Required
Please answer the following health screening questions as this information is required to be included on your referral to the program.
Pre exercise screening questions
Has your doctor every told you that you have a heart condition or have you suffered a stroke? *
Do you ever experience unexplained pains in your chest at rest or with physical activity/exercise? *
Do you ever feel faint or dizzy or lose your balance whilst undertaking exercise/physical activity? *
Have you had an asthma attack requiring immediate medical attention within the last 12 months? *
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. *
Do you have any other conditions that may require special consideration for you to exercise? *
If yes, please provide short answer (ie sore back)
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