DFFL Exercise Screening Form pdf

DONNA FITZ FIT LIFE

Client Screen Form & Consent

Name:

Date of Birth:

Date

Address:

Mobile:

Occupation

Emergency Contact Name & Contact Number:

Doctor Name & Contact Number:

Do you take part in regular exercise?

If 'Yes' please list:

How often do you exercise in one week?

How long do you exercise for?

What intensity do you exercise at? (Light, Moderate, Hard)

What is your preferred type of exercise?

Do you Smoke?

If SO, how many a day?

Do you drink Alcohol?

If SO, how many units per week?

Note: 1 unit = ½ pint of beer / one glass wine / one measure of spirits

Would you describe your lifestyle as?

Please answer yes or no to the following-

Rows	Yes	No
Are you currently taking any form of medication?
Is there any family history of heart disease under the age of 55?
Have you ever been advised by a doctor not to exercise?
Have you had an injury in the last 3 months?
Are you now or have you been pregnant in the last 3 months?
Have you had surgery in the last 3 months?
Are you suffering from any back, joint, muscle or bone complaints?

If you have answered 'yes' to any of the above, please give details here

Do you suffer or have you suffered form any of the following?

Rows	Yes	No
Heart Disease
High or Low Blood pressure
High Cholesterol
Diabetes
Arthritis
Asthma, or other lung problems
Back, Knee or Joint problems
Hernia
Epilepsy
Anaemia
Muscle Pain or injury
Any Chonic Illness

If you answered yes to any of the above questions, please explain here-

Are there any other reasons not stated in this questionnaire which would prevent you from taking part in an exercise class or program?

INFORMED CONSENT

I agree to take part in the exercise class as described & instructed to me by the instructor. I understand that in order to be effective my exercise will change and progress as time goes on and all guidance and correction offered is in my best interests. The nature, purpose, risks and benefits have been explained to me and I understand what is required of me and that I may withdraw from any exercise session or from the programme at any time. I declare to the best of my knowledge that the above details are correct and should circumstances change it is my duty to inform the instructor. I understand that the activities I participate in are at my own risk. I understand the nature of this screening questionnaire and that there are risks and dangers inherent in physical activity. I will inform the instructor of any medical conditions, injuries or allergies I have or if any of the above information changes.

Signed:

Date:

Date

Pre & Post Natal Medical Screening Section

Have you had any of the following in the last 3 months:

Rows	Yes	No
C- Section Delivery
Multiple Gestations
Gestational Diabetes
Gestational Hyper Tension
Any bleeding during pregnancy
Prior Foetal Loss- Ectopic/ Miscarriage
Diagnosed SPD in Pregnancy or Diastis Recti of the Abdomen
Do you have GP clearance to exercise? (please provide a letter if pregnant or within 12 weeks post partum)

Any other details to note please list here. Please inform your instructor if any of the above details change at any time.

Signed:

Date:

Date