1:1 Telehealth Consult

SECTION A: Personal & Emergency Details

SECTION B: Medical History & Screening (ESSA-Aligned)

Please tick all boxes that are true:

SECTION C: Exercise Goals & Barriers

SECTION D: Exercise Status & Support Preferences

SECTION E: Lifestyle, Work & Tech

SECTION F: Fees & Medicare Rebate Information

Initial Consult (60 mins):

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🗸 Cost: $80

🗸 Medicare rebate (if referred under CDM): $58.30

Includes:

• Comprehensive Health & Lifestyle HistoryExploration of medical conditions, injuries, medications, mental health, fatigue, menstrual factors, and relevant history.

• Functional Needs & Goal MappingCollaborative discussion around what you want to achieve, barriers you're facing, and areas where support is most needed (e.g. pain management, returning to work, sport, daily activity, or managing a condition).

• Assessments Tailored to Your Goals, which may include:

• Basic strength & mobility checks (e.g. sit-to-stand, balance, reach, range of motion)

• Cardiovascular tolerance (e.g. walking tolerance, breathlessness with tasks)

• ADLs & fatigue scales (if managing chronic conditions or flare-ups)

• Workload or task-specific capacity (if returning to work or sport)

• Patient-reported outcome measures (e.g. pain scales, confidence, mental wellbeing)

• Behavioural & readiness assessments (e.g. motivation, confidence, flare triggers)

• Education & Goal-Oriented PlanExplanation of how movement can support your goals, and discussion around realistic frequency, formats (e.g. at-home, gym, walking), and what’s safe and sustainable for you.

• Program PrescriptionA tailored movement plan provided as a PDF or online Physitrack program, with options for pacing, modifications, and symptom monitoring.

• Tech & Access SupportSetup help to access your program, record symptoms, or follow structured progressions independently (or with review options).

Subsequent Sessions (45 mins):

🗸 Cost: $60

🗸 Medicare Rebate (if eligible): $58.30

Includes:

• Check-in on how your program is going

• Review of symptoms, fatigue, flare-ups, or improvements

• Update of your exercise plan and progressions

• Education and coaching around lifestyle, motivation, or pacing

• Optional retesting of previous assessments (e.g. strength, tolerance)

SECTION G: Consent & Waiver (Telehealth Delivery)

Please read and confirm:

By submitting this form, I acknowledge and agree to the following:

• I understand that telehealth delivery has limitations compared to in-person care.

• I have answered all questions truthfully and to the best of my knowledge.

• I have been informed of the risks and benefits of exercise and participate voluntarily.

• I accept that exercise carries inherent risks (e.g. discomfort, injury, flare-ups).

• I will notify my clinician if I feel pain, dizziness, or breathlessness during exercise.

• I release TeleMoves and its team from liability related to telehealth-delivered programs.

• I understand all advice is based on the information I’ve provided.

SECTION H: Book Your Session

Once submitted, you’ll be directed to book your appointment online.

Final Note About Referrals

If you are claiming Medicare

• Upload your GP referral now (above), or

• Email it to [telemoves@outlook.com] at least 24 hours before your consult.