PRE-EXERCISE SCREENING QUESTIONAIRE

Date of Assessment *
Date of Assessment
Personal Details:
Name *
Name
DOB *
DOB
GOALS
ACTIVITY:
NUTRITION
PRIMARY HEALTH QUESTIONS
1. Have you been told you have a heart condition or suffered from a stroke? *
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? *
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that cause you to lose balance? *
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *
5. If you have diabetes (type I or type II) have you had any trouble controlling your blood glucose in the last 3 months? *
6. Do you have any muscle, bone or joint problems that you have been told could be made worse through exercise? *
RISK FACTOR QUESTIONS
1. Are you over the age of 45 (male) or 55 (female)? *
2. Do you have a family history of heart disease (parent, sibling or child)? *
3. Do you smoke cigarettes on a daily or weekly basis, or have you quit smoking in the last 6 months? *
4. Do you participate in more than 150 minutes of exercise each week? *
5. Have you ever been told you have high blood pressure? *
6. Have you ever been told you have high cholesterol? *
7. Have you ever been told you have high blood sugar? *
ADDITIONAL HEALTH QUESTIONS
1. In the last year have you spent time in hospital (including day admission) for any medical condition/injury? *
2. Are you currently taking prescribed medication for any medical conditions? *
3. Are you currently pregnant or have you given birth in the last 12 months? *
4. Do you have any other medical conditions that may impact your ability to participate in physical activity? *
I believe to the best of my knowledge that all of the information provided for this Pre-Exercise Screen is accurate and correct. I also consent for Daniel Chapelle to contact my nominated Doctor/Physician, Specialist/Allied Health Professional for additional medical clearance/information if required? *