CLIENT DETAILS:
Name: __________________________________________ D.O.B______________________
Address:____________________________________________________________________
Contact Number:____________________________________________________________
1. Goals for participating in this program are: ( please tick or cross )
0 Improve balance 0 Increase fitness 0 Increase flexibility
0 Increase social contact 0 Prevent health problems 0 Increase strength
2. Does the client have any of the following health conditions?
__ Respiratory problems
__ Diabetes
__ Back problems
__ High blood pressure
__ Joint conditions
__ Joint replacement
__ Heart conditions
__ Neurological conditions
__ Cancer
__ Osteoporosis
__ Chronic pain
__ Other___________________________________________________________________
Details of conditions:___________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Current Medication? If yes, please list:____________________________________________
__________________________________________________________________________
__________________________________________________________________________
REFERRAL DETAILS:
Medical Practitioner Name:_____________________________________________________
Organization/Facility:_________________________________________________________
Address:____________________________________________________________________
Phone:_____________________________________________________________________
Reason For Referral:
___________________________________________________________________________
___________________________________________________________________________
Providers Signature:____________________________________________________________
Date:_______________________________________________________________________
