Skip to content
Essence Fitness
More than just a 24hr Gym
1 Bay Road, Claremont WA 6010
(08) 9386 8588
Email Us
Home
Our Club
Cardio Zone
Free Weights
Pin Loaded Weight Machines
Functional Zone
Memberships
What We Do
Exercise Physiologist services
Strength for Life
Chronic Disease Management Programme (Care Plans)
Type 2 Diabetes Programme
Department of Veteran Affairs (DVA)
Personal Training
Foundation Programs
Weight Loss
Class Timetable
Paediatric and Sports Physiotherapy
Massage
MyWellness App
Our Team
Bill Grace
Mike Price
Gino Saccoccio
Alison Dymond
Emma Walkey
Nadia Monaco
Jayde Thompson
Gordon Niner
Amelia Foulkes
Blog
Contact Us
Adult Pre-Exercise Screening Form
Home
»
Adult Pre-Exercise Screening Form
Adult Pre-Exercise Screening Form
Adult Pre-Exercise Screening Form
Step 1 of 5 - Personal Details
20%
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)
Date Format: DD dash MM dash YYYY
Gender
*
Male
Female
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:
*
ADDITIONAL MEDICAL INFORMATION
All 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?
*
Yes
No
Please provide more detail on why you have high blood pressure levels:
*
Have you been told that you have high cholesterol?
*
Yes
No
Please provide more detail on why you have high cholesterol levels:
*
Have you been told that you have high blood sugar?
Yes
No
Please provide more detail on why you have high blood sugar levels:
*
Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months?
*
Yes
No
Please specify why you have spent time in hospital:
*
Are you currently taking a prescribed medication(s) for any medical conditions(s)?
*
Yes
No
If yes, what is the medical condition(s)?
*
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?
*
Yes
No
As you have muscle, bone or joint pain or soreness that is made worse by particular types of activity, please specify:
*
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
CAPTCHA