2024 FLINDERS LIVING - MEMBERSHIP FORM

This screening tool is part of the Adult Pre-Exercise Screening System (APSS) that also includes guidelines (see User Guide) on how to use the information collected and to address the aims of each stage. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise & Sport Science Australia, Fitness Australia, Sports Medicine Australia or Exericse is is Medicine for any loss, damage, or injury that may arise from any person acting on any statement or infromation contained in this system.

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*

YesNo

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

YesNo

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

YesNo

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

YesNo

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

YesNo

Do you have any other condition that may require special consideration for you to exercise?*

YesNo

If you answered 'Yes' to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

Medical Certificate:

By signing this form you can confirm you are 18 years of age and above and have read and agree to all the terms and conditions above. The information you have provided is true and correct.*

YesNo

Date*

Date

Signature*

FLINDERS LIVING - MEMBERSHIP FORM

MEMBERSHIP INFO

Adult Pre-Exercise Screening System