Course Date: / / Today Sdate: /

Health Questionnaire

Course Title: …………………………………………………………………………………………………………

Course Date: ……../……../...... Today’sDate: ……../……../......

During practical sessions that involve learning, refining, and practising assessment and treatment techniques, all students are expected to participate as both practitioners and models under the supervision of table tutors. To enable us to best serve your needs during the course, please complete and return this health questionnaire at your earliest convenience.

This information will remain confidential and will only be viewed by your Table Tutors and the Course Director (and by office staff for administrative purposes only).

Date of Birth: / Name:
Do you have a history of physical trauma or injury? / If yes please give details and advise if the condition has stabilised.
Are you currently receiving treatment for a medical condition? eg
CVS (Hypertension)
Respiratory, GIT, GU
Neuro-Endocrine
Other
Yes No / If yes please give details and advise if the condition has stabilised.
Are you currently receiving treatment for a psychological or mental health condition?
Yes No / If yes please give details and advise if the condition has stabilised:
Do you have any pain or discomfort at present?
Yes No / If yes please give details:eg location, type, onset
Are you experiencing higher than usual levels of stress at present?
Yes No / If yes please give details:
Do you have any current mobility or flexibility issues?
Yes No / If yes please give details:
Have you been hospitalised in the past year?
Yes No / If yes please give details:
Do you have a history of any serious or chronic illnesses?
Yes No / If yes please give details: e.g. chronic fatigue, hepatitis, auto-immune dysfunctions.
.
Please list any medication you are currently taking or have taken for an extended period in the past.
Is there anything else you would like to mention about your health?
(Please advise if you are pregnant).

Thank you for your cooperation in filling in this questionnaire. Following this course, the information will be retained in a file by the Executive Officer of the SCTF of ANZ for the statutory period. If you have any concerns or questions, or wish to speak to the Course Director in confidence,please contact the SCTF ANZ on we can best assist you.

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