Clone of Pre-Exercise Health and Fitness Screening

Disclaimer

This screening tool is not medical advice and does not guarantee safety. It should be used as a guide only, and professional judgment should always be applied.

Name:

First NameLast Name

Age

Enter age in years.

Gender

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:

How did you hear about us?

Emergency Contact:

NamePhone Number

Health History Section

Answer Yes or No to each question. If you answer Yes to any question, you should not begin or continue unsupervised exercise until you have sought medical advice.

1. Do you have a heart condition or a history of stroke?

2. Do you experience chest pain or discomfort during rest or exercise?

3. Do you experience dizziness, fainting, or loss of balance during exercise?

4. Have you had an asthma attack requiring medical attention in the last 12 months?

5. Have you had blood sugar control issues related to diabetes in the last 3 months?

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

7. Family history of heart disease?

8. Any hospital admissions in the last 12 months?

9. Do you smoke?

If yes, what is your smoking quantity?

If applicable, provide the amount you smoke.

10. Pregnancy or recent birth status?

11. High blood pressure?

Any medication that you take for it:

12. High cholesterol?

Any medications that you take for it:

13. Any other prescribed medications:

If you answered Yes to questions 1-9, please provide any further details below:

Physical Activity Section

Record how many days per week and how many minutes per day you usually spend in each activity intensity.

Light intensity activity frequency per week

Enter the number of days per week.

Light intensity activity duration per day (minutes)

Enter the usual minutes per day.

Moderate intensity activity frequency per week

Enter the number of days per week.

Moderate intensity activity duration per day (minutes)

Enter the usual minutes per day.

Vigorous intensity activity frequency per week

Enter the number of days per week.

Vigorous intensity activity duration per day (minutes)

Enter the usual minutes per day.

Total weighted minutes

Multiply the minutes by the number of days for each and the add all of them together

Guidance: A total of less than 150 weighted minutes per week suggests the amount of activity may be insufficient. A total of 150 or more weighted minutes per week is generally a more active level.

How would you describe your level of activity within your job?

Nutrition

On a general basis, what does your current daily nutrition consist of?

Rows
Breakfast
Mid Morning
Lunch
Mid Afternoon
Dinner
Dessert
Other Eg. alcohol, take away

Injuries

Back

Neck

Head

Legs (R,L)

Shoulder (R,L)

Other Injuries:

Any musculoskeletal conditions affecting exercise:

Exercise Limitations

What exercises (if any) are you unable or struggle to perform?

Other notes relating to training

CLIENT DECLARATION

I HAVE READ, FULLY UNDERSTOOD AND COMPLETED THIS QUESTIONNAIRE. THE ANSWERS I HAVE GIVEN ARE ACCURATE TO THE BEST OF MY KNOWLEDGE.

Signature

Date

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Pre-Exercise Health and Fitness Screening Questionnaire