Adult Pre-Exercise Screening Form HomeAdult Pre-Exercise Screening Form Adult Pre-Exercise Screening Form Adult Pre-Exercise Screening Form Step 1 of 5 - Personal Details 20% PERSONAL DETAILSAll questions marked * below are mandatory, please fill them all out. Name(Required) Email(Required) Date of Birth(Required)Please enter a date in the format (dd-mm-yyyy) DD dash MM dash YYYY Gender(Required)MaleFemale MEDICAL DETAILSAll questions marked * below are mandatory, please fill them all out. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)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?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?(Required) Yes No As you answered YES to the question above, please provide more detail(Required)Does your Family have a history of heart disease (eg: stroke, heart attack)(Required) Yes No Please select the family members that have had heart disease(Required) Father Mother Brother Sister Son Daughter As you selected your Father, please specify his age(Required) As you selected your Mother, please specify her age(Required) As you selected your Brother, please specify his age(Required) As you selected your Sister, please specify her age(Required) As you selected your Son, please specify their age(Required) As you selected your Daughter, please specify their age(Required) LIFESTYLE INFORMATIONAll questions marked * below are mandatory, please fill them all out. Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?(Required) Yes No As you are smoking, how many per day or week?(Required) Describe your current physical activity/exercise levels:(Required) Sedentary Light Moderate Vigorous Light Exercise(Required)Frequency session per weekDuration minute per weekModerate Exercise(Required)Frequency session per weekDuration minute per weekVigorous Exercise(Required)Frequency session per weekDuration minute per weekAre you training for a specific sport or event?(Required) Yes No As you are training for a specific sport or event, please specify:(Required)Do you have any exercise dislikes?(Required) Yes No Please specify the exercises you dislike:(Required) ADDITIONAL MEDICAL INFORMATIONAll questions marked * below are mandatory, please fill them all out. Please state your height (cm) Please state your weight (kg) Have you been told that you have high blood pressure?(Required) Yes No Please provide more detail on why you have high blood pressure levels:(Required)Have you been told that you have high cholesterol?(Required) Yes No Please provide more detail on why you have high cholesterol levels:(Required)Have you been told that you have high blood sugar? Yes No Please provide more detail on why you have high blood sugar levels:(Required)Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months?(Required) Yes No Please specify why you have spent time in hospital:(Required)Are you currently taking a prescribed medication(s) for any medical conditions(s)?(Required) Yes No If yes, what is the medical condition(s)?(Required)Are you pregnant or have you given birth within the last 12 months? Yes No Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity?(Required) Yes No As you have muscle, bone or joint pain or soreness that is made worse by particular types of activity, please specify:(Required) FINAL STEPSAll questions marked * below are mandatory, please fill them all out. I believe that to the best of my knowledge, all of the information I have supplied within this form is correct.(Required) Yes
