Unit 1, 23 Ashtan Place, Banyo, QLD 4014
1300 663 243
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Client Information
Client First Name
First
Client Last Name
Last
Date of Birth
Address
Suburb
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Contact Information
Parent/Carer Details
Contact First Name
First
Contact Last Name
Last
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Contact Mobile
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Referrer Information
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Last
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*
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Medical Information
Medical Conditions and Diagnosis
Height cm
Weight kg
Assistance needed for communication
Yes
No
Are there any other medical details that we should be aware of?
Mobility Information
Are they any mobility aids being used such as a walker, powerchair, etc. If yes, please describe
Are they any restricted movement in hips/knees/ankles?
Have they had botox within the last three months?
Yes
No
Bike Information
Have they ridden a bike before?
Yes
No
What are the main challenges with riding a bike?
Are they likely to require the following
Postural support
Thoractic support
Foot cups
Unsure
Funding
These questions are optional
Country of Birth
Indigenous Status
Torres Strait Islander Origin
Aboriginal Origin
Both
Neither
Living Arrangements
Lives with family
Other
How will the bike be paid for?
Self
NDIS
CAEATI
Betterstart
Other
Other
How
How did you hear about the Freedom Wheels program
Word of Mouth
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Event
Previous Client
Website
Other
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