Physiotherapy
By Sport
Australian Rules Football
Basketball
Cricket
Cycling
Dance
Golf
Hiking
Netball
Rowing
Running
Skiing
Soccer
Swimming
Tennis
By Condition
Achilles Tendinopathy
Ankle Sprains
Anterior Ankle Impingement
Calf Injuries
Frozen Shoulder
Hamstring Injuries
Hip Injuries
Knee Meniscus Injuries
Shoulder Rotator Cuff Injuries
Spondylolisthesis
Tennis Elbow
Medical
Healthy Aging
Bone Health
Falls Prevention
Clinical Pilates
Restore Clinical Pilates
Pre and Post Natal Clinical Pilates
Real Time Ultrasound
Women’s & Men’s Health
Blog
About Us
Who is Restore
Staff Profiles
Fees & Payment
Client Survey
Careers
Contact Us
Book Online
Onero Weight Lifting Screening Questionnaire
ONERO Weight Lifting Screening Questionnaire
Name:
Date of birth:
Age:
Medical History
Please tick Yes or No
Heart disease/cardiac procedure
Yes
No
Chest pain
Yes
No
High blood pressure (BP)
Yes
No
If yes, is your BP well controlled
Yes
No
Diabetes
Yes
No
If yes, is your diabetes controlled
Yes
No
Stroke / TIA
Yes
No
Lung condition (eg. COPD, asthma)
Yes
No
Arthritis/chronic joint pain
Yes
No
Joint replacement
Yes
No
If yes, which joint/s:
Back or neck pain
yes
No
Back surgery
Yes
No
Incontinence
Yes
No
Pelvic prolapse or pelvic surgery
Yes
No
Hernia or surgery for hernia
Yes
No
Balance problems or dizziness
Yes
No
Neurological condition eg MS, Parkinsons
Yes
No
Falls in the past 12 months
Yes
No
Current or previous history of cancer
Yes
No
Dementia
Yes
No
Hospital admission in past 12 months
Yes
No
Osteoporosis/osteopaenia (low bone density)
Yes
No
Have you had a DEXA (bone density) scan?
Yes
No
T-score total lumbar spine (if known)
T-score femoral neck (if known)
Have you suffered a fracture from minimal trauma?
Yes
No
Have you had blood tests for osteoporosis?
Yes
No
Have you had a urine test for osteoporosis?
Yes
No
Have you had dietary advice for bone health?
Yes
No
Are you taking medications for bone health?
Yes
No
Are you taking supplements for bone health?
Yes
No
Do you participate in resistance training?
Never
Past
Current
How many minutes of exercise do you do per week?
Please list all current medications/supplements that you are taking and the conditions for which you take them:
Please list the name and addresses of current GP and specialists: (By providing this information, you consent for Restore Physiotherapy to contact the above providers, if required, for safe exercise prescription)
Participant Declaration:
I confirm that the information provided is accurate and I agree to notify staff of any changes.
Signature:
Date:
reCAPTCHA
SEND