Adult Pre-Exercise Screening Form

PERSONAL DETAILS
All questions marked * below are mandatory, please fill them all out.
Name*
Email*
Date of Birth*
Please enter a date in the format (dd-mm-yyyy)
Gender*

MEDICAL DETAILS
All 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?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
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?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?*
- Yes
- No
As you answered YES to the question above, please provide more detail*
Does your Family have a history of heart disease (eg: stroke, heart attack)*
- Yes
- No
Please select the family members that have had heart disease*
- Father
- Mother
- Brother
- Sister
- Son
- Daughter
As you selected your Father, please specify his age*
As you selected your Mother, please specify her age*
As you selected your Brother, please specify his age*
As you selected your Sister, please specify her age*
As you selected your Son, please specify their age*
As you selected your Daughter, please specify their age*

LIFESTYLE INFORMATION
All 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?*
- Yes
- No
As you are smoking, how many per day or week?*
Describe your current physical activity/exercise levels:*
- Sedentary
- Light
- Moderate
- Vigorous
Light Exercise*
Frequency session per week Duration minute per week
Moderate Exercise*
Frequency session per week Duration minute per week
Vigorous Exercise*
Frequency session per week Duration minute per week
Are you training for a specific sport or event?*
- Yes
- No
As you are training for a specific sport or event, please specify:*
Do you have any exercise dislikes?*
- Yes
- No
Please specify the exercises you dislike:*

FINAL STEPS
All 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.*
- Yes
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Adult Pre-Exercise Screening Form

Step 1 of 5 - Personal Details

PERSONAL DETAILS

All questions marked * below are mandatory, please fill them all out.

MEDICAL DETAILS

All questions marked * below are mandatory, please fill them all out.

LIFESTYLE INFORMATION

All questions marked * below are mandatory, please fill them all out.

ADDITIONAL MEDICAL INFORMATION

All questions marked * below are mandatory, please fill them all out.

FINAL STEPS

All questions marked * below are mandatory, please fill them all out.

Mon - Thurs:	7am - 12pm / 4 - 7pm
Friday:	7am - 12pm
Saturday:	8 - 11am