Pre-Exercise Screening

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. This assists our Exercise Physiologists to keep you safe and promote awareness when performing group exercise sessions, exercise testing and/or exercise programming.

General Information

Patient first name *

Patient surname *

Date of birth *

Email Address

Home phone

Mobile phone

Street Address *

City *

State *

Postcode *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Health Information

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 activty/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 conditions that may require special consideration for you to exercise? *

YesNo

Current Exercise/Physical Activity

Please indicate how many light intensity exercise sessions you complete per week (Light Intensity is no noticeable change in breathing) *

How many total light exercise minutes per week? *

Please indicate how many moderate intensity exercise sessions you complete per week (Moderate intensity defined as a change in breathing but can still maintain a conversation) *

How many total moderate exercise minutes per week? *

Please indicate how many vigorous intensity exercise sessions you complete per week (Vigorous defined as noticeable change in breathing, unable to maintain conversation) *

How many total vigorous exercise minutes per week? *

Please Indicate the total exercise minutes per week (light + moderate + 2x vigorous) *- If your total is less than 150 minutes per week 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 per week then continue with your current physical activity/exercise intensity levels.

Location and Type of Exercise Session

Please fill in this section if you are wanting specifically to join one of our exercise group sessions, otherwise please tick "Not Applicable".

Choose the type or types of exercise class you would like to participate in?

Hydrotherapy (Pool Based Exercise)Land Based Exercise GroupNot Applicable

Other

Are you already booked in to attend a group class with Healthy Lifestyles Australia?

YesNo. Please call me to book me in. Not Applicable

Consent

I confirm that above information I have provided is true, complete and accurate. *

Signature *

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Date *

The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Healthy Lifestyles Australia, Exercise & Sport Science Australia, Fitness Australia, Sports Medicine Australia or Exercise is Medicine for any loss, damage, or injury that may arise from any person acting on any statement or information contained in this system.

I understand this form will be used by the Healthy Lifestyles Australia Exercise Physiologist to assess my suitability for participation in exercise, exercise testing, group program or fitness challenge. A face to face or phone consultation may be required prior to participation to ensure your safety, if 1 or more of the initial 6 questions of this form are ticked yes (you will be made aware if this is required).

Section to be Completed by Healthcare Professional

This section can be left blank if you are completing this form by yourself. Please click submit at the end of the survey if you have finished. If this form is being completed in conjunction with a healthcare professional they fill in this section.

Suitable for participation in group classes and exercise sessions? (Healthcare professional only)

YesYes, however with the below considerationsNo, requires medical clearance before participationNo, not suitable for participation

Considerations for inclusion or exclusion of group classes and exercise therapy. And/Or considerations for participation.

Signature of Healthcare Professional

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Date

Type of Healthcare Professional

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