Pre Exercise Screening Questionnaire Form
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1Pre 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
Yes
No
2.
Has your doctor ever told you that you have a heart condition?
Yes
No
3. Do you ever experience unexplained pains in your chest at rest or during physical
activity/exercise?
Yes
No
4. Do you ever feel faint or have spells of dizziness during physical activity/exercise
that causes you to lose balance?
Yes
No
5. Have you had an asthma attack requiring medical attention at any time over
the last 12 months?
Yes
No
6. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in
the last 3 months?
7. Do you have any other medical condition(s) that may make it dangerous for you to participate
Yes
No
in physical activity/exercise? __________________________________________________________
Yes
No
8. 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.
IF YOU ANSWERED ‘NO’ to all questions, and you have no other concerns about your health, you may proceed to undertake light-
moderate intensity physical activity/exercise
I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
Member/Visitor Signature_________________________________________
Date_______________
Employee Signature______________________________________________
Date_______________
Doc No: SafetyFirst- 05.02
Version No: 1.1
Issue Date: 09/14
Next Review: 09/15
Owner: National WHS Manager
Approved By: National Human Resources Director
V1 (2011)
P
1
age
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