Personal information

Your Name:

Your Email:

Address:

Telephone:

Date of birth:

Occupation:

Person to be contacted in case of emergency

Contact name:
Telephone:

Medical history

Main issue:

Any other issues which may be relevant:

Medications you are currently taking:

Consent Form for assessment with Lisa Brown (Innervate Health & Fitness Pty Ltd)
General Outline
: Since every client is different I will decide as to which assessments to perform as we proceed. The general procedure is to begin with a patient interview to determine relevant medical and physical activity history. We will then perform the appropriate assessments to try and determine the cause of your pains and then try and identify strategies for you to remove the cause together with some appropriate and specific exercise patterns.

Please note that I am one of only 3 qualified McGill Method Certified Practitioners* in AUS/NZ.
*A McGill Method Certified Practitioner has training in assisting clients in reducing the risk of disabling low back pain and injury, optimising their health outcomes and enhancing their performance. The McGill Method Certified Practitioner has studied how to use information obtained from history taking and movement assessment to better match corrective/therapeutic and performance enhancement exercise. They will also have been exposed to nuances of technique to reduce a client’s pain. I am not a qualified physician or physiotherapist.
Interview: The interview consists of questions to help me determine what motions and loads exacerbate your back pain or those that are well tolerated by you. I also want to know about the type of pain, location, whether you have good and bad days etc. This information helps us to determine safe tasks for you to do.
Functional movement screens: These back specific assessments are intended to quantify how your back moves together with the specific causes of pain. You will be requested to adopt certain postures to see if they cause discomfort together with some very light loading activities. For example, different sitting postures can reveal different sources of back pain. You will know if they worsen or help your back pains and I ask that you indicate this to me when prompted.
It is important that you are aware that there is a possibility that you will be sore after the assessment and for the next day. This happens on occasion but these are really minimal exertion and loading assessments.
Consent of Participant
The 'Trainer' refers to the Australian Registered Business 'Innervate Health & Fitness'.
The 'Activity' refers to the participation in functional movement screen assessment.

I have read the information presented above about the procedures and risks involved in the activity and have received satisfactory answers to my questions. I am aware that I may withdraw from the activity at any time. I acknowledge that a condition of participating in this activity is that I do so at my own risk. I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, and any person directly and indirectly associated with the trainer against all liability claims, demands and proceedings arising out of or connected with my participation in this activity.

I certify that I am 18 years or older and have read this document and fully understand it OR as a parent or guardian of the participant (a) I agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the terms referred to I have a read, understand and agree to the trainers policies (as disclosed in this document).

I have read and agree to the above policy

Dated: