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Health Screening Questionnaire

Client Health Screening Questionnaire

Your safety comes first.

Please complete this questionnaire honestly and accurately before participating in Thrive Recovery services. The information you provide helps our team identify potential health and safety risks and determine whether further review is required before using particular services.

Some medical conditions, medications or injuries may mean that certain services are unsuitable or require medical clearance. Completing this questionnaire does not automatically mean you are cleared to use every service.

Section 1 — Personal Information

First Name

Last Name

Date of birth

Date completed

Email address

Mobile number

Emergency Contact

Full name

Relationship

Contact number

Section 2 — General Medical Information

1. Have you been diagnosed with any medical conditions?

Yes

If yes, please provide details.

2. Are you currently under the care of a doctor or medical specialist?

Yes

If yes, please provide details relevant to your participation in recovery services.

3. Have you undergone surgery within the past 12 months?

Yes

If yes, please provide details.

4. Do you currently have any injuries or physical limitations?

Yes

If yes, please provide details.

5. Are you currently taking any prescription medications?

Yes

If yes, please list relevant medications or provide details for confidential review.

6. Have you previously experienced an adverse reaction to heat, cold exposure, pressure changes or compression therapy?

Yes

Unsure

If yes or unsure, please explain.

7. Are you currently pregnant, or could you be pregnant?

Yes

Unsure

Prefer not to disclose

Section 3 — General Health Conditions

Please select any conditions you currently have or have previously experienced. If none apply, select "None of the above" for each group.

Cardiovascular Health

High blood pressure

Low blood pressure

Heart attack

Irregular heartbeat or arrhythmia

Stroke or transient ischaemic attack (TIA)

Chest pain during physical activity

Heart failure or other significant heart condition

None of the above

Respiratory Health

Asthma

Chronic obstructive pulmonary disease (COPD)

Chronic lung disease

Previous pneumothorax (collapsed lung)

Difficulty breathing

Other respiratory condition

None of the above

Neurological Conditions

Epilepsy or seizures

Stroke

Concussion

Brain injury

Vertigo

Fainting episodes

Other neurological condition

None of the above

Musculoskeletal Conditions

Neck injury

Back injury

Disc injury

Osteoporosis

Arthritis

Recent fracture

Joint replacement

Other musculoskeletal condition

None of the above

Skin and Circulatory Conditions

Open wounds

Skin infection

Severe eczema

Psoriasis flare-up

Recent burns

Raynaud's disease

Poor circulation

Previous deep vein thrombosis (DVT) or blood clot

None of the above

If you selected any condition above, please provide any additional information relevant to your recovery sessions.

Section 4 — Service-Specific Health Screening

Please answer the following questions for services you intend to use. Selecting a condition does not automatically mean you are permanently excluded from a service. It indicates that further assessment may be required.

Which services do you intend to use?

Hyperbaric Oxygen Therapy (HBOT)

Whole Body Cryotherapy

Cold Plunge

Infrared Sauna

Compression Boots

Red Light Therapy

A. Hyperbaric Oxygen Therapy (HBOT)

Do you currently have, or have you previously experienced, any of the following?

Pneumothorax (collapsed lung)

Ear surgery or significant ear problems

Difficulty equalising ear pressure

Chronic sinus problems

Lung disease

Recent chest surgery

Current fever, respiratory infection or significant congestion

History of seizures

Claustrophobia or significant anxiety in enclosed spaces

None of the above

If any condition applies, please provide details.

B. Whole Body Cryotherapy

Do you currently have, or have you previously experienced, any of the following?

Raynaud's disease

Cold urticaria or cold allergy

Poor circulation

Peripheral vascular disease

Uncontrolled high blood pressure

Significant heart condition

Diabetes with reduced sensation

Reduced ability to feel cold or temperature changes

Previous fainting or severe dizziness during cold exposure

None of the above

If any condition applies, please provide details.

C. Cold Plunge

Do you currently have, or have you previously experienced, any of the following?

Significant cardiovascular condition

Uncontrolled high blood pressure

Raynaud's disease

Cold urticaria or cold allergy

Poor circulation

Reduced temperature sensation

Previous fainting or severe dizziness during cold-water immersion

Difficulty entering or exiting a bath safely

Open wounds or an active contagious skin infection

None of the above

If any condition applies, please provide details.

D. Infrared Sauna

Do you currently have, or have you previously experienced, any of the following?

Low blood pressure

Heat intolerance

Severe dehydration

Kidney disease

Significant heart condition

Previous fainting during heat exposure

A medical condition or medication affecting sweating or temperature regulation

None of the above

If any condition applies, please provide details.

E. Compression Boots

Do you currently have, or have you previously experienced, any of the following?

Deep vein thrombosis (DVT)

Known or suspected blood clot

Blood clotting disorder

Severe peripheral arterial disease

Severe or unexplained leg swelling

Open wounds or active infection in the treatment area

Significant heart failure or another condition affecting fluid balance

None of the above

If any condition applies, please provide details.

F. Red Light Therapy

Do you currently have, or have you previously experienced, any of the following?

Photosensitivity

Use of photosensitising medication

Active skin cancer in the proposed treatment area

An eye condition requiring specific protection

Previous adverse reactions to light-based treatments

None of the above

If any condition applies, please provide details.

Section 5 — Current Health Status

If you are currently unwell or experiencing concerning symptoms, please notify Thrive Recovery before attending. A new or unexplained medical concern may require postponement of your session or medical assessment.

Are you currently experiencing any of the following?

Fever or acute illness

Chest pain

Unexplained shortness of breath

Dizziness or faintness

Significant dehydration

New or unexplained swelling

Active infection

None of the above

Section 6 — Additional Information

Is there anything else about your health, medical history or physical condition that you believe Thrive Recovery should know before you participate?

Section 7 — Privacy and Health Information Consent

Thrive Recovery collects the personal and health information provided in this questionnaire to assist with service safety screening, identify potential risks, determine whether further review is required and maintain relevant customer records. Your questionnaire is submitted through our website and delivered to Thrive Recovery's business email account. Your participation waiver is completed separately through Momence. Your information will be handled in accordance with Thrive Recovery's Privacy Policy and applicable privacy laws.
Read Thrive Recovery's Privacy Policy

I have read the privacy information above and consent to Thrive Recovery collecting, using and storing my health information for the purposes described.

I consent

Section 8 — Customer Declaration

Please confirm each of the following:

I declare that the information provided is accurate and complete to the best of my knowledge.

I confirm

I understand that withholding relevant medical information may increase my risk of injury or adverse events.

I confirm

I agree to notify Thrive Recovery of relevant changes to my health, medications or medical circumstances before participating in future sessions.

I confirm

I understand that completing this questionnaire does not automatically establish my suitability for every service.

I confirm

I understand that Thrive Recovery may require further review or appropriate medical clearance before allowing me to participate in certain services.

I confirm

I understand that I must also complete the required participation waiver through Momence before attending a session.

I confirm