Pre-Physio Medical and Consent


ACCPrivate



YesNo


SedentaryLightMediumHeavyVery Heavy


AloneWith partner/spouseOther


CancerHeart ProblemsGastrointestinal disorderOsteoporosis / Low bone densityRheumatoid Arthritis or other rheumatoid conditionDiabetesDepression / AnxietyKidney diseaseStroke / blood clotsNone of the above


FatigueGeneral feeling of unwellnessFever/Chills/SweatsNausea/VomitingNumbness, tingling or weakness in ANY part of the bodyDizziness / Light headednessChange in mental ability (e.g. confusion, memory loss)HeadachesNight PainSustained morning stiffnessTraumaConstipationEasy bruisingChanges in visionNONE OF THE ABOVE


YesNo


YesNo


YesNo


YesNo



CancerDiabetesHeart DiseaseStrokeNone of the above



YesNo

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