Get Pre Exercise Questionnaire Template

Pre Exercise Screening Questionnaire This screening tool does not provide advice on a particular matter nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Fitness First Exercise and Sports Science Australia Fitness Australia or Sports Medicine Australia for any loss damage illness injury or death that may arise from any person acting on any statement or information contained in this tool. Name Phone No M F DOB Emergency Contact Phone AIM to identify those individuals with a known disease or signs or symptoms of disease who may be at a higher risk of an adverse event during physical activity/exercise. Pre Exercise Screening Questionnaire This screening tool does not provide advice on a particular matter nor does it substitute for advice from an appropriately qualified medical professional* No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Fitness First Exercise and Sports Science Australia Fitness Australia or Sports Medicine Australia for any loss damage illness injury or death that may arise from any person acting on any statement or information contained in this tool* Name Phone No M F DOB Emergency Contact Phone AIM to identify those individuals with a known disease or signs or symptoms of disease who may be at a higher risk of an adverse event during physical activity/exercise. This checklist is self administered and self evaluated* Please circle response 1. Have you ever suffered or been told by a doctor that you have suffered a stroke Yes No 2. Has your doctor ever told you that you have a heart condition Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance Have you had an asthma attack requiring medical attention at any time over the last 12 months If you have diabetes type I or type II have you had trouble controlling your blood glucose in Do you have any other medical condition s that may make it dangerous for you to participate in physical activity/exercise 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 IF YOU ANSWERED YES to questions 1 - 6 we recommend you obtain written medical clearance/approval from a GP or appropriate allied health professional stating your are able to safely undertaking physical activity/exercise in our clubs. I believe that to the best of my knowledge all of the information I have supplied within this tool is correct. Member/Visitor Signature Employee Signature Doc No SafetyFirst- 05. 02 Version No 1. 1 Issue Date 09/14 Next Review 09/15 Owner National WHS Manager V1 2011 Approved By National Human Resources Director Page 1.