ONERO Registration and Medical History

Demographics

Title *

Gender *

First Name *

Surname *

Date of Birth *

Address *

Include Suburb

Email Address *

Mobile Phone *

If no mobile phone insert contact person mobile number

Medicare Number

Ref

Medicare Expiry

Private Health Insurance

Membership Number

Referring General Practitioner *

Usual General Practitioner (if different)

Other Interested parties / include contact details

Emergency Contact, Next of Kin

Name

Contact Number

Relationship

Medical History

The answers to these questions contribute to creating a safe and effective management program.

Age *

Hand Dominance *

Right Hand Dominant

Left Hand Dominant

Ambidextrous

Which hand do you use to write with or perform most activities with?

Occupation / If retired what did you do previously *

Height (cm) *

Weight (Kg) *

Sport & Hobbies *

Sport & Hobbies Previous

If Different eg Gymnastics

Weekly Exercise *

List usual weekly exercise routine.

Do you have any restrictions to exercise?

eg injury, pain, balance

What problems have you experienced? (indicate all relevant) *

What surgery or operation/s have you had?

General Health - please indicate which health conditions you have or have had *

List any other medical conditions or injuries

eg Fractured wrist as a child

Are there any conditions that run in your family?

eg Diabetes, Inflammatory arthritis, Psoriasis

Smoking *

Never

Ex Smoker

Smoke or smoked 0 - 10 / day

Smoke or smoked 10 - 20 / day

Smoke or smoked > 20 / day

Years Smoked less 0 - 10 yrs

Years Smoked 10 - 20 yrs

Years Smoked > 20 yrs

Smokers & Ex smokers may tick several boxes as approriate

Alcohol *

Never

1 - 5 drinks / week

6 - 10 drinks / week

11 - 15 drinks / week

16 - 20 drinks / week

> 20 drinks / week

Previously more

What regular medications are you currently taking?

What Supplements are you currently taking?

Investigations

Email results/ reports of DEXA scans and relevant other investigations prior to the appointment. Alos bring all previous investigations with you to the appointment. Some but not all, xrays can be accessed online by Emilie. She is unable to access xrays or scans done in a public hospital.

Where were Scans performed?

Where were Blood tests / Pathology performed?

Nil

SEALS

Douglass Hanly Moir

Laverty

SydPath

Other

Reason for Booking ONERO? *

eg Osteopaenia, Fracture, Family History

Terms of Service

Consent *

Terms and Conditions Please read and sign the waiver. Our terms and conditions are listed over the page. Waiver By Participant You acknowledge our terms and conditions below. The above named has made an Application to participate in the Onero™ program, delivered by the licensee of the Onero™ program AND by signing this document you acknowledge that you understand and agree that: 1. Onero™ is the Trademark of an exercise program, including: a. progressive resistance training b. weight-bearing impact activities C. balance challenge tasks 2. You acknowledge that the program is generally designed for and targeted to men and women of any age, with low bone density with an emphasis on exercise which may minimise further loss of bone density. 3. It is recommended that you complete two sessions per week, with at least one rest day in between your sessions. You are able to choose the days and times of your sessions of the program within the limits of your Onero trainers availability.. 4. The Onero™ Licensee will ensure that a suitably qualified Coach is present at all times when you are training and that you will be able to interact with the Coach to the extent that is necessary and appropriate. 5. You acknowledge that the coaching you will receive and that your participation in the program is for the purpose of exercise instruction and guidance. You also acknowledge that the Coaches are not qualified to diagnose or treat any illness whatsoever and that any concerns you have regarding any health conditions or illnesses should be brought to the attention of the relevant medical practitioner by you. 6. You acknowledge that you have informed the Onero™ licensee of any health conditions or illnesses you suffer or have suffered in the past which may, in the opinion of your medical practitioner, be relevant to your participation in the program and the manner in which participation in the program may affect you. 7. You acknowledge that the Onero™ program is not a cardiovascular training program, but that some hopping / jumping / high-impact activities could raise your heart rate above the resting rate for an amount of time. 8. You acknowledge that the Onero™ program does not include specific endurance training. 9. The Onero™ licensee maintains, at all times, public liability insurance to include active participation in the Onero™ program. 10. YOU ACKNOWLEDGE THAT you are agreeing to participate in the program voluntarily and that you release the Onero™ licensee, Onero™ Pty Ltd and The Bone Clinic Pty Ltd from any claims, demands, and actions at law that may arise as a consequence of your performance of Onero™ activities, including exercises, or any injury or condition that you may suffer. YOU MUST AGREE TO THESE TERMS AND CONDITIONS OF USE BEFORE ENTERING THE ONERO™ TRAINING FACILITY By SIGNING our waiver, you acknowledge that you have read these terms and conditions and you agree to be bound by them without limitation or qualification. If you do not agree to these terms and conditions, you do not have our consent and should cease to use our facility immediately. The Onero™ licensee ("Us”, “We” or “Our") reserves the right, at our discretion, to change, modify, add or remove portions of these terms at any time. Therefore, we suggest that you review these terms periodically for changes. By using our facility after we have posted changes to these terms and conditions of use, you are agreeing to be bound by these terms as amended. TERMS AND CONDITIONS 1. There are no joining or exit fees. 2. Each session must be paid for at the time of booking. 3. There are no refunds for missed sessions, 4. You acknowledge you are agreeing to participate in the exercise program voluntarily and that you release the Onero™ licensee, Onero™ Pty Ltd and The Bone Clinic Pty Ltd from any claims, demands, and actions at law that may arise as a consequence of your performance of Onero™ activities, or any injury or condition that you may suffer. IP PROTECTION You understand that, to be effective, the Onero™ program must be delivered and administered: 1. Exactly as prescribed by Us, without any amendment, omission or addition, and 2. Strictly within the limits of and according to the protocols we develop, and 3. Under the direct supervision of a registered physiotherapist or exercise physiologist (or equivalent, in international locations), and who is certified as a Coach by The Bone Clinic Pty Ltd and that accordingly, you will not, and will not attempt or seek to: • Explain or describe Onero™ to another, to educate another about Onero™ or to implement Onero™ with another, or; • Be involved or interested in the development, delivery, implementation or advertisement of any other exercise programme which is like Onero™, or; • Do anything whereby the intellectual property rights of The Bone Clinic Pty Ltd or Onero™ Pty Ltd may be prejudicially affected or challenged, or; • Copy, reproduce, vary or adapt in any way, either in whole or in part, any manual, program template or other document relating to Onero™. Woollahra Sailing Club, 2 Vickery Ave, Rose Bay 2029. emilie@myhand.com.au

Consent

Please Note we have a 12 hour cancellation policy for all training appointments.

Onero Consent *

Agree

No

I agree to the ONERO Terms and conditions above.

Appointment Confirmation *

Agree

No

You will receive confirmation via email for your upcoming appointment. It is your responsibility to reply to confirm your appointment.

Consent to Treatment *

Agree

No

I consent to receiving treatment techniques that my therapist deems most suitable for my condition based on a thorough examination and scientific evidence. In general, treatments used (physio, exercise testing, nutrition) are very safe, however I understand that there may be a very small risk associated with some treatment techniques (eg. Using gym equipment, taping, heat/ice therapy). Emilie Myers is insured via the Australian Physiotherapy Association policy.

Communicate *

Agree

No

I am happy for my therapist to communicate with my doctor/s (GP, Specialist, Surgeon), coaches and other health professionals regarding my injury/issue to inform of treatments, recommendations. and progress reports.

Voice Transcription *

Agree

No

Therapists may use voice transcription for clinical note-taking. I consent to the use of voice-to-text documentation during consultations.

Text Messages *

Agree

No

I consent to receiving text messages to confirm appointments

Emails *

Agree

No

I consent to receiving email messages to confirm appointments

Signature *

Date