Name
*
First Name
Last Name
NDIS number
*
Date of Birth
*
MM
DD
YYYY
Phone
Country
(###)
###
####
Email
*
NDIS Plan start date
*
MM
DD
YYYY
NDIS Plan end date
*
MM
DD
YYYY
Plan manager/ support coordinator details:
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Plan management company / support coordinator name, phone, email
Will a support worker be attending with you?
*
Support worker Name/details:
Emergency contact NAME
*
Emergency contact PHONE & EMAIL
*
Emergency contact RELATIONSHIP
*
Main health condition/ disability (as reported on your NDIS plan)
*
Please describe your disability and main health condition/s. Include date of diagnosis.
Goals
We are really excited to be on your team and are ready to help you achieve your goals. It’s really important to celebrate the little wins along the way to achieving bigger goals such as the ones you set out in your NDIS plan.
Structured exercise provides a wonderful setting for acknowledging every achievement big and small which we hope will provide motivation to stay focused on the process at hand.
Goals and aspirations can be great motivations to stay committed and consistent with your health, fitness and wellness routines. However they can become overwhelming or a source of frustration if mindsets and circumstances change. It is totally normal to feel this way, we are all human. But be sure to stay aware of these changes and associated emotions and re asses and reset your goals.
Please let us know if you’re feeling stuck or overwhelmed and we can work with you in figuring out how to re group and re focus. It may be time to tweak your goals or vary your program.
Please list and describe the goals you set on your NDIS plan:
Are there any other goals or areas you would like to work on that are not outlined in your NDIS plan goals?
For example. “I would like to be able to walk/run 5km by the end of the year”, “I would like to be fit enough to go on a holiday that will require lots of walking"
ACTIVITY HISTORY
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What exercise or movement practices have you tried or participated in the last 12 months
Can you provide some further details of your experience with this exercise?
Did you enjoy it? Did you feel better for doing it? Did you hate it? Was it a chore? Did you enjoy seeing the people there or was it something you did alone?
Any information is useful for us so we can tailor this program to be successful for you
Are you a male over 35 or female over 45 and NOT used to regular exercise? Y N
Has your doctor ever said that you have heart trouble?
Do you have a family history of cardiovascular disease/ heart troubles?
Have you given birth in the past 8 weeks? Y / N
Do you suffer from any of the following:
If you answered yes to any of the medical questions above, please provide additional detail:
Do you take any prescription medication?
Does your medication have any adverse effects we should be aware of when taking you through an exercise session? (for example dizziness, essential tremor, excessive thirst or need to go to the toilet etc)
Your treating health care professionals
We believe in an integrative and holistic approach to your health and wellness. Therefore we are more than happy and would love to be in communication with your treating doctors so we can all work together to give you the best care. If you agree to us contacting your relevant health care professionals (e.g. GP, physio, psychologist, case worker etc) Please share their contact details
Total Stressor score out of 90
Total score for healthy behaviours and social support out of 90
SIGNED
Date
MM
DD
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