Exercise Training Readiness Assessment HomeExercise Training Readiness Assessment Exercise Training Readiness Assessment Health Questionnaire Step 1 of 8 - Personal Details 0% PERSONAL DETAILSAll questions marked * below are mandatory, please fill them all out. Name(Required) Date of Birth(Required)Please enter a date in the format (dd-mm-yyyy) DD dash MM dash YYYY Gender(Required)MaleFemaleContact Number(Required)Address(Required) Street Address Suburb Post Code Occupation Private Health Insurance Fund EMERGENCY CONTACT DETAILSAll questions marked * below are mandatory, please fill them all out. Emergency Contact Name First Last Emergency Contact Phone MEDICAL DETAILSAll questions marked * below are mandatory, please fill them all out. General Practitioner Name First Last General Practitioner Address Street Address Suburb State Post Code General Practitioner Contact numberGeneral Practitioner Email Where did you hear about the Living Longer Living Stronger program? Newspaper Radio Website Other Location You have selected Other Location (Please specify)(Required) Please tick the appropriate box if you have, ever had, or are on medication for; Heart problems Diabetes Discomfort in the chest at rest or exertion High cholesterol Epilepsy High blood pressure Asthma, emphysema, bronchitis - other lung problems Stroke Discomfort in the legs at rest or exertion Hernia Arthritis or major injuries in any joints Osteoporosis Severe vein disorders in the legs, or feet, or ulcers Swollen feet/ankles Liver condition Glandular fever Kidney condition Eating disorder Rheumatic fever Dizziness/fainting Cancer Other Medication (please specify) You have selected Other Medication (Please specify)(Required) CARDIO-PULMONARY SYSTEMAll questions marked * below are mandatory, please fill them all out. 1. Do you have, or have you experienced the following: Epilepsy Fainting Convulsions Seizures Dizzy spells 2. Have you ever had pain or pressure, either at rest or during exercise: In the middle of the chest On the left side of the chest In the neck region At the left shoulder or down the left arm 3.1 Do you take any medications for Heart Disease Yes Please specify Heart Disease Medication Name(Required)3.2 Do you take any medications for Diabetes Yes Please specify Diabetes Medication Name(Required)3.3 Do you take any medications for Cholesterol Yes Please specify Cholesterol Medication Name(Required)3.4 Do you take any medications for Blood Pressure Yes Please specify Blood Pressure Medication Name(Required)3.5 Do you take any medications for Asthma or any other Breathing Problems Yes Please specify Breathing or Asthma Medication Name(Required) NEURO MUSCULARAll questions marked * below are mandatory, please fill them all out. 4. Do you have any impairments of the following? (tick appropriate box) Thermal (temperature control) Motor sensory Vision or hearing Speech/ language 5. Have you ever experienced a brain or spinal injury? Yes No 6. Do you have, or do you experience: Poor balance / instability Pressure sores Unsteady gait (walking) 7. In the previous 12 months have you experienced: Severe cramps Concussion Unexplained muscle soreness Persistent headaches / nausea 8. Have you suffered any nervous system injury? Lesion of or damage a nerve Numbness or pins and needles Other You have Selected Other Nervous System Injury (please specify):(Required) MUSCULO SKELETALAll questions marked * below are mandatory, please fill them all out. 9. Have you experienced any muscular pain in the last six months? Yes Please specify the muscular pain you had:(Required)10. Have you experienced any joint pain in the last six months? Yes Please specify the joint pain you had:(Required)11. Have you broken any bones in the last 12 months? Yes Please specify which bones were broken:(Required)12. Have you had any musculo-skeletal or joint problems requiring treatment or joint replacement? Yes Please explain by including the problem, treatment and treating physician:(Required)13. Do you, or a blood relative, suffer from a musculo-skeletal problem, such as osteoporosis or arthritis? Yes As you selected yes to question #13, please explain:(Required) GENERAL HEALTHAll questions marked * below are mandatory, please fill them all out. 14. Do you have any neurological disorder which may require special needs whilst exercising? Examples may include: Parkinson’s, Alzheimers, or Motor Neurone Disease, Multiple Sclerosis, Downs Syndrome, Cerebral Palsy, or Dementia, or short term memory Yes No If yes, please specify:(Required)15. Are you aware of any medical reason/condition which might prevent you from participating in an exercise program? Yes If yes, please specify:(Required)16. Do you have any allergies which may affect your capacity/ ability to exercise? Yes If yes, please specify:(Required)17. Do you have chronic fatigue syndrome? Yes 18. Have you had surgery in the previous 12 months? Yes If yes, please specify:(Required)19. Is there any other medical conditions not covered that you would like us to know about? Yes If yes, please specify:(Required) FINAL STEPSAll questions marked * below are mandatory, please fill them all out. Please list any medication you are taking (including headache pills) and the frequency of use (click the + icon to add additional medications):MEDICATION/DRUGDailyWeeklyMonthly Add RemoveI believe that to the best of my knowledge, all of the information I have supplied within this form is correct.(Required) Click to agree CAPTCHA
