top of page

1:1 Telehealth Consult

SECTION A: Personal & Emergency Details

Gender

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

Please tick all boxes that are true:

Please answer Yes or No to the following:
Are you currently taking any medications?
Yes
No

SECTION C: Exercise Goals & Barriers

What would you like help with? (Tick all that apply)
What barriers are affecting your activity?

SECTION D: Exercise Status & Support Preferences

How often do you currently exercise?
How often do you plan or want to exercise?
Do you experience pain, shortness of breath, or discomfort during exercise?
Yes
No
Do you need support with any of the following?

SECTION E: Lifestyle, Work & Tech

Do you have access to the following?
Preferred program format:
Home equipment available (tick all)
Preferred session frequency:

SECTION F: Fees & Medicare Rebate Information

Initial Consult (60 mins):

Add your text

🗸 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.

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
Day
Month
Year

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.

Goal-Based Training

Section A: Basic Information

Gender

Section B: Exercise & Health Status

Tick any that apply to you:

Section C: Goal Selection (Tick all that apply)

What would you like your program to focus on?

Please fill in any extra details that will help your Exercise Physiologist tailor your program:

Section D : Exercise Experience & Environment

How often do you currently exercise?
How often do you want or plan to exercise using this program?
Where do you currently exercise or expect to complete this program?
What equipment do you have access to?

Section E: Barriers to Exercise

Do you experience any of the following barriers to exercise?
Would you like your program to include tips for motivation, planning, or staying consistent?

Section F: Final Comments

Section G: Waiver of Liability and Informed Consent

By submitting this form and participating in the program developed by TeleMoves, you agree to the following:

  • You understand that the program is based solely on the information you have provided and is not equivalent to a clinical consultation or medical clearance.


  • You confirm that you are medically fit to participate in physical activity, or have sought appropriate advice from a healthcare professional.


  • You acknowledge the inherent risks of exercise, including injury, strain, or exacerbation of a pre-existing condition.


  • You agree to take full responsibility for your health and safety during participation, and will cease exercise and seek medical attention if you experience pain, dizziness, shortness of breath, or other concerning symptoms.


  • You release and indemnify TeleMoves, its staff and representatives from any liability, injury, or claim that may arise from your participation in the program.

Pre-Made Programs

IMPORTANT: Please Read Before Purchasing

By proceeding to purchase and download this exercise program, you acknowledge and agree to the following:

  • I understand that this program is general in nature and does not constitute medical advice or individualised clinical assessment. It is not tailored to your personal health conditions, limitations, or goals.


  • I have been advised to consult your general practitioner or appropriate health professional before commencing any new exercise program, particularly if you have a pre-existing medical condition, injury, or any concerns about your physical capability.


  • I voluntarily choose to undertake physical activity and accept the inherent risks associated with exercise, which may include but are not limited to: musculoskeletal injury, cardiovascular events, aggravation of pre-existing conditions, or other health complications.


  • I acknowledge that participation is at your own risk, and you assume full responsibility for any and all injuries, losses, or damages that may occur through the use of this program.


  • I hereby release and discharge TeleMoves, its founder, staff, contractors, and affiliates from any liability or claim for damages or injuries sustained through participation in this program.


  • I agree that this waiver applies to you and anyone who may use this program under your direction.

bottom of page