Self-referral form

Personal information

Given name *

Preferred name

Family name *

Date of birth *

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Email address

Telephone number *

Address (VIC residents only)

Do you identify as Aboriginal and/or Torres Strait Islander?

• Yes
• No

Reason to see Physiotherapist

Do you have a support person or carer?

• Partner
• Family member
• Parent/guardian
• Carer

Do you need a translator?

• Yes
• No

Language spoken

What are your current living arrangements?

• Living at home alone
• Living with someone else or family member
• Living in remote location
• Living near other neighbours for example

If you have any questions regarding this form or need assistance in completing this form, please contact us on 5122 6015. Thank you!

Please note that we will be in contact with you to arrange an appointment within 2 to 3 working days of receiving your information.

Please complete your medical history below.

Medical history

Has your medical practitioner ever told you that you have a heart condition, or have you ever suffered a stroke? *

• Yes
• No

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

• Yes
• No

Do you ever feel faint, dizzy, or lose balance during physical activity/exercise? *

• Yes
• No

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

• Yes
• No

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

• Yes
• No

Do you have any other conditions that may require special consideration for you to exercise? *

• Yes
• No

Have you experienced any of the following?

Bladder or bowel incontinence *

• Yes
• No

Numbness in the groin/between your legs *

• Yes
• No

Loss of sexual function *

• Yes
• No

Sudden, unintentional weight loss *

(greater than 10% in the last 6 months, or 5% in the last month)

• Yes
• No

Unexplained night pain *

• Yes
• No

Further information

Do you have a family history of heart disease? (stroke, heart attack, etc) *

• Yes
• No

If yes, please provide their relationship to you, the age of their condition’s onset, and what the condition was

Do you currently smoke, or have you quit smoking in the last 6 months? *

• Yes
• No

If currently smoking, please provide the number per day or week

Have you ever had any form of cancer? *

• Yes
• No

If yes, please provide details
(Including treatment received, type of cancer, and current cancer status)

Have you been told that you have high blood pressure? *

• Yes
• No

If yes, please provide your most recent BP reading (if known).
Are you taking any medication for this?
What is it?

Have you been told that you have high cholesterol/blood lipids? *

• Yes
• No

Any medications you are taking for this

Do you have diabetes (T1 or T2?) *

• Yes
• No

If yes, do you have:
Any numbness or altered sensation in the lower limbs/feet? (Neuropathy)
Any vision loss or eye damage?
Any skin sores or ulcers?
Please provide details.
If using any medication, please note these as well

Do you have any respiratory disease? *

• Yes
• No

If yes, please provide details
When were you diagnosed?
What is the severity of your COPD (if known)?
When was your last spirometry date, and what were the results? (if known)
Do you use home oxygen?

Do you have any neurological conditions? *

(e.g. Parkinson’s, multiple sclerosis, nerve damage, peripheral neuropathy, etc)

• Yes
• No

If yes, please provide details including
What is the condition?
Are you using any medication to manage it?

Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise? *

• Yes
• No

If yes, provide further details.

Have you spent time in hospital for any condition/illness/injury over the last 12 months? *

(including day admission)

• Yes
• No

If yes, provide details

Have you given birth within the last 12 months? *

• Yes
• No

If yes, provide details

Have you had any falls in the past 12 months? *

• Yes
• No

If yes
How many falls?
When was your most recent fall?
What caused your fall?

Do you use any walking aids? *

• Yes
• No

If yes, please provide details;

Do you have any diagnosed mental health conditions? *

• Yes
• No

If yes, provide further details
Including any medication you may be taking to help manage it

Is there anything else you feel you should disclose for our screening purposes?

Consent to seeking further information *

In some cases, we may request further information from your GP or other healthcare providers to ensure we have all relevant health information to best support your care. Do you consent to us contacting your GP or other relevant professional for any information we may require related to your physiotherapy care?

• Yes
• No

GP Name and clinic

GP clinic contact number

Thank you for taking the time to complete this information. We will be in contact with you to arrange an appointment within 2 to 3 working days of receiving this information. Please be assured that all telehealth consultations are private, confidential and adhere to the same clinical standards as face-to-face consultations at your local health service.
You can find more information about your privacy here.