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Section 1 – Patient Details (All Fields Compulsory*)

First Name * :
Surname * :
Gender * :	MaleFemale
Date of Birth:
Ethnicity:
Street Address:
Suburb * :
Postcode:
Home Phone * :
Mobile:
Email:

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Section 2 – Medical conditions or physical impairments (Please check boxes which relate to you)

Respiratory ConditionsCVDHigh Blood PressureHeart ConditionsHigh/Low Blood PressureArthritisInjuryStrokeJoint ReplacementOsteoporosisCognitive ImpairmentUnsteady When Standing or WalkingUses a Walking Aid

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Other Relevant Information

Please Note: you will require your own transport to classes. This is NOT provided as part of this service

Section 3 - Falls Risk Factor Screening

Any trips, slips, falls (or near falls) in past year?	NoYes
Can’t get out of a chair without using your hands?	NoYes
Limits or avoids activities because afraid of losing balance or falling?	NoYes

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Section 4 - Physical Activity

Are you currently participating in any form of physical activity? If so, what activities and how often?

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Signed Date * :

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