General BFR Screening Form

1. Tell us about you...

First Name *

Last Name *

Date Of Birth *

Email Address *

Mobile phone number

If you've had pain due to this condition, think of the average pain you have had in the past week. Rate your AVERAGE pain on a scale of 0 to 10, where 10 is the worst pain imaginable and 0 is no pain. *

Rate the strength of the affected body part(s). (Where 0 is No Strength, and 10 is Very Strong) *

When you think about all the things you want to do with your affected body part(s), rate your ability from 0 to 10, where 0 is unable and 10 is completely able. *

IMPORTANT INFORMATION WE NEED TO KNOW

I have ticked any and all the Precautions that apply to me *

Precautions tally

REGARDING PRECAUTIONS: We will need to get more information from you before we can say if BFR is suitable for you - BFR may or may not be safe for you.

If you ticked Just one or two boxes, your risk may be Low to Moderate. We may be able to make adjustments to suit you.

If you have ticked more than 3 boxes, your risk could be considered High and we may need to look at Alternatives, as we will not take chances with your health.

Please complete the rest of the Questionnaire. If you are able to go ahead, this will provide important information. If you are not able to go ahead we will be able to provide you with alternative methods of managing your knee problem.

I have ticked any and all the Contraindications that apply to me *

Contraindications tally

STOP sign

Based on your responses today, it does not appear that you will be able to safely participate in Blood Flow Restriction (BFR) Training.

However, there are likely to be other exercise options that will be suitable for you - there always are!

If you would like advice on how to address your goals and needs, let's keep your momentum going to take some action to improve your health.

Once you have submitted this form you will receive an email giving information on what alternative ways you have of accessing our services. Look out for it - check your "Junk/Spam" folder in case it went there!

We do look forward to helping you out as we have many ways of helping people move and feel better!

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Well, all looks good so far.

We will be in touch to assist you further.

Or you can contact us directly to book for BFR assessment:

Mingara (in Tumbi Umbi) - (02) 4388 9944

Ettalong Beach - (02) 4342 1590

Umina Beach - (02) 4327 8444

Thanks for completing this Questionnaire - it will provide valuable information that we can use to demonstrate how much you improve through your active participation!

Once you have hit Submit your responses will be recorded in your Clinical Notes and you will receive an email including information on how to prepare for the Assessment or what Alternatives are available to you..

You will also receive a phone call from us to arrange the best day and time for your Initial Assessment, where we will measure your current levels of strength and function. Or we can help advise on what to do if BFR is not for you. Please note, there is no obligation to proceed with a booking - we'll call and discuss but it's completely up to you if you want to go ahead!

Talk to you soon!

All the best from the Physios and Exercise Physiologists at 6S PHYSIO

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