Adult Pre-Exercise Screening Form

Adult Pre-Exercise Screening Form
Name

First NameLast Name
Email
example@example.com
Date of Birth
Mobile Number
Aim: to identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual.

This stage may be self-administered and self-evalualted by the client, please complete the questions below:
1. Has your medical practitioner ever told you that you have a heart condition or have your ever suffered a stroke?
2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
3. Do you ever feel faint, dizzy or lose balance during physical exercise/activity?
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 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
6. Do you have any other conditions that may require special consideration for you to exercise?
If you answered Yes to any of the 6 questions, please seek medical guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise

If you answered No to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/exercise per week

7. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities:

Rows	Light (no change in breathing)	Medium (can maintain a converstaion)	Vigourous/High (cannot maintain a conversation/interrupted)
Intensity
Frequency (no. of sessions per week)
Duration (Total no. of minutes per week

WEIGHTED PHYSICAL EXERCISE PER WEEK TOTAL MINUTES = Minutes of light +moderate + 2 x minutes of vigourous/high
If your total is less than 150 minutes per wewek, then light to moderate intensity exercise is recommended. Increase your volume and intensity slowly.

If your total is more than or equal to 150 minutes then continue with your current physical activity/exercise intensity levels

It is advised that your discuss any progressions (volume, intensity, duration, modality) with an exercise professional to optimize your results
8. Are you currently taking any medication for any conditions?
9. Do you have any diagnosed muscle, bone, tendon, ligament, or joint problems that you have been told could be made worse during exercise?
10. Have you had any recent hospitalization for any condition/illness/injury in the last 12 months. If so, please provide details
What are your goals for a fitness program on both an overall health and fitness level?
I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.
Date:
Signature

Privacy Policy
Chocolate Fitness
Belinda Eady
Email: jazbin@optusnet.com.au
Phone: 0413 120 768

Chocolate Fitness is committed to protecting your privacy and handling your personal information in a secure and responsible manner. This Privacy Policy explains how personal information is collected, used, stored, and managed.

Collection of Personal Information
Chocolate Fitness collects personal information that is reasonably necessary for providing fitness and wellness services. Information collected may include:

Name
Contact details, including phone number and email address
Information provided through a Pre-Exercise Screening Questionnaire
Any other information voluntarily provided by clients
The Pre-Exercise Screening Questionnaire is used to obtain general health information to assist in identifying potential risks and determining the suitability and scope of fitness activities and services.

Purpose of Collection
Personal information is collected for the purpose of:

Providing personal training and fitness services
Assessing health and fitness requirements
Managing client participation and safety
Communicating with clients regarding services and activities
Maintaining accurate client records
Storage and Security of Information

Personal information is collected and stored securely through the Jotform platform.

Chocolate Fitness takes reasonable steps to protect personal information from misuse, interference, loss, unauthorised access, modification, or disclosure. Security measures include password protection and restricted access to records.

Only Belinda Eady of Chocolate Fitness has access to client information.

Disclosure of Information
Chocolate Fitness does not sell, share, rent, or disclose personal information to third parties.

Personal information is not disclosed to overseas recipients.

Information is used solely for the purposes outlined in this Privacy Policy.

Access and Correction
Clients may request access to their personal information and request corrections if the information is inaccurate, incomplete, or out of date.

Requests for access or correction should be directed to Belinda Eady using the contact details provided above.

Changes or corrections to records can only be made by Belinda Eady.

Retention and Disposal of Information
Personal information will be retained for as long as required to fulfil the purpose for which it was collected and to meet any legal or administrative obligations.

Where a client's status has not been resubmitted through a new Waiver, personal information will be deleted after ten (10) years.

When personal information is no longer required, Chocolate Fitness will take reasonable steps to securely destroy or permanently de-identify the information to prevent unauthorised access, use, or disclosure.

Complaints
If you believe your personal information has been mishandled or that Chocolate Fitness has breached its privacy obligations, you may lodge a complaint by contacting:

Belinda Eady
Chocolate Fitness
Email: jazbin@optusnet.com.au
Phone: 0413 120 768

All complaints will be reviewed promptly and confidentially. Chocolate Fitness will acknowledge receipt of the complaint, investigate the matter, and provide a written response outlining the outcome and any actions taken to address the concern.

If you are not satisfied with the outcome of your complaint, you may seek further advice from the Office of the Australian Information Commissioner (OAIC).

Changes to this Privacy Policy
Chocolate Fitness may update this Privacy Policy from time to time. Any updated version will replace previous versions and will be made available upon request.

Last Updated: June 2026
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