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Essence Fitness
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1 Bay Road, Claremont WA 6010
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Exercise Training Readiness Assessment
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Exercise Training Readiness Assessment
Exercise Training Readiness Assessment
Living Longer Living Longer Questionnaire
Step 1 of 8 - Personal Details
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PERSONAL DETAILS
All questions marked * below are mandatory, please fill them all out.
Name
*
Date of Birth
*
Please enter a date in the format (dd-mm-yyyy)
Date Format: DD dash MM dash YYYY
Gender
*
Male
Female
Contact Number
*
Address
*
Street Address
Suburb
Post Code
Occupation
Private Health Insurance Fund
EMERGENCY CONTACT DETAILS
All questions marked * below are mandatory, please fill them all out.
Emergency Contact Name
First
Last
Emergency Contact Phone
MEDICAL DETAILS
All 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 number
General 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)
*
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)
*
CARDIO-PULMONARY SYSTEM
All 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
*
3.2 Do you take any medications for Diabetes
Yes
Please specify Diabetes Medication Name
*
3.3 Do you take any medications for Cholesterol
Yes
Please specify Cholesterol Medication Name
*
3.4 Do you take any medications for Blood Pressure
Yes
Please specify Blood Pressure Medication Name
*
3.5 Do you take any medications for Asthma or any other Breathing Problems
Yes
Please specify Breathing or Asthma Medication Name
*
NEURO MUSCULAR
All 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):
*
MUSCULO SKELETAL
All 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:
*
10. Have you experienced any joint pain in the last six months?
Yes
Please specify the joint pain you had:
*
11. Have you broken any bones in the last 12 months?
Yes
Please specify which bones were broken:
*
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:
*
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:
*
GENERAL HEALTH
All 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:
*
15. Are you aware of any medical reason/condition which might prevent you from participating in an exercise program?
Yes
If yes, please specify:
*
16. Do you have any allergies which may affect your capacity/ ability to exercise?
Yes
If yes, please specify:
*
17. Do you have chronic fatigue syndrome?
Yes
18. Have you had surgery in the previous 12 months?
Yes
If yes, please specify:
*
19. Is there any other medical conditions not covered that you would like us to know about?
Yes
If yes, please specify:
*
FINAL STEPS
All 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/DRUG
Daily
Weekly
Monthly
I believe that to the best of my knowledge, all of the information I have supplied within this form is correct.
*
Click to agree
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