Strength & Balance For Healthy Ageing
Falls Prevention Program
I AM SIGNING UP FOR THE FOLLOWING LOCATION
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MARGARET RIVER: 09:15am-10:15am at the Margaret River Men's Shed
COWARAMUP: 11:00am-12:00pm at the Duggan Pavillion
CLIENT DETAILS
Answer N/A in the fields below if not applicable
First Name:
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Last Name:
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Address:
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Date of Birth:
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Contact Number:
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Email Address:
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Emergency Contact Name
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Emergency Contact Number
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I give consent for my emergency contact to be called if needed
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Yes
No
Please contact me to discuss
In the unlikely event of an emergency, I want an ambulance to be called for me if needed
Yes
No
Please contact me to discuss
PRE EXERCISE SCREEN
MEDICAL HISTORY:
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Please tick the box if you have any of the following?
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Heart conditions
Neurological conditions
Bloody pressure high
Blood pressure low
Vertigo/dizziness/fainting
Chronic pain
Recent surgeries
Arthritis (OA or RA)
Osteoporosis
Have you had a fall/s before? If yes, please give further detail
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Has there been a fall in the last 6 months?
What is the most important thing you hope to get out of this program?
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I acknowedge that the information provided is true and correct to the best of my knowledge
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By ticking this box, I give consent for photos or videos of me to be taken. I understand that this media may be used on local and national news, social media platforms and marketing material to promote falls prevention and healthy aging.
I acknowledge that this course involves movement. Whilst precautions are taken by the course providers for my safety, I acknowedge that I am participating at my own risk and assume all liability. I will promptly communicate to the course coordinators how I am feeling during each session throughout the course, including any concerns that may impact on my participation. If I use mobility aids for safe walking, I will ensure that I bring this along to each session.
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Completed By:
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Signature:
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Clear
Date:
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