MediGYM Pre-Exercise Assessment Form
A personalised program will be developed based on assessment findings, diagnosis and discussed goals. The program will be implemented with progress monitored regularly.
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Sex
Male
Female
Prefer not to say
Other
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State
Post code
Occupation
(Optional)
Emergency Contact (Name)
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
How did you hear about MediGYM?
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Medical Information
Have you ever had, or do you have:
Rows
YES
NO
1. High blood pressure
2. Heart condition or stroke
3. Diabetes (IDDM or NIDDM)
4. Liver or kidney condition
5. Stomach ulcers
6. High Cholesterol (normal: 3.9-5.5)
7. Rheumatic or Glandular fever
8. Gout
9. Epilepsy
10. Osteoporosis
11. Osteopenia (thin bones)
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Medical Issues
Do you experience, have you experienced or are you on medication for:
Rows
YES
NO
COMMENT
1. Pain, tightness or discomfort in chest when resting or on exertion?
2. Breathing difficulties, asthma, emphysema, bronchitis/ other lung problems?
3. Back pain (please comment if upper/lower back or both as well as severity)?
4. Neck pain (please comment on how mild / moderate / severe)?
5. Arthritis (please comment on what type and whether you have had joint replacements)?
6. Muscular pain or joint pain or cramps?
7. Do you have a hernia?
8. Do you have any bowel, bladder or pelvic floor dysfunction(s)?
9. Any major injuries or illnesses e.g. cancer?
10. Regular headaches or migraines?
11. Do you smoke (please comment on how much and whether you were a past smoker)?
12. Do you have a chronic cough?
13. Have you been hospitalised lately?
14. Any infections or infectious diseases ?
15. Are you going through menopause?
16. Have you had or are you concerned about falling?
17. Are there any conditions that may limit your activity program?
18. Do you ever feel faint/have dizzy spells, during exercise that causes you to lose balance?
19. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise?
Is there a family history of chronic heart disease, stroke or raised cholesterol?
YES
NO
Please list any surgery (and dates) and / or any other health condition(s) here:
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Medication
Please list your current medication(s) here:
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Exercise Experience
In an average week, on how many days would you do at least 30-minutes of any moderate intensity physical activity e.g. walking, gentle cycling or swimming)?
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week
How intensive is your current level of exercise?
As if sitting doing nothing
1
2
3
4
5
6
7
8
9
Could not possibly do anymore
10
1 is As if sitting doing nothing, 10 is Could not possibly do anymore
Have you ever attended a structured exercise session?
YES
NO
When was your last structured exercise attendance?
Why did you stop or leave?
What physical activities do you currently engage in?
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Goals
Please list your main goal(s) for exercising:
What activities are you unlikely to complete (i.e. due to limitations or avoidance)?
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Signature
Date
-
Day
-
Month
Year
Date
Signature
Submit
Should be Empty: