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?

YesNo

2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

YesNo

3. Do you ever feel faint, dizzy or lose balance during physical exercise/activity?

YesNo

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

YesNo

5. If you have diabetes, (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

YesNo

6. Do you have any other conditions that may require special consideration for you to exercise?

YesNo

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:

	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