ADULT PRE-EXERCISE SCREENING TOOL
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. No responsibility or liability whatsoever can be accepted by trainer for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.
Stage 1(Compulsory)
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 stage is self-administered and self-evaluated.
1.
Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Yes
No
2.
Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?
Yes
No
3.
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Yes
No
4.
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
Yes
No
5.
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
Yes
No
6.
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
7.
Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?
Yes
No
IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise
IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise
Stage 2(Compulsory)
8.
What regular exercise are you doing at the moment?
9.
Are you currently satisfied with your body, health and well being?
Yes
No
10.
Have you been to a fitness/health Club before?
Yes
No
11.
How long have you wanted to achieve the results you desire?
12.
Where do your preferences lie? Tick the one that most suits your needs.
Lose Weight & Tone Up
What results are most important?
Number 1-5
  • Reduce Body Fat
  • Toning
  • Reshaping
  • Increase Metabolism
  • Improve Self Esteem
Improve Strength & Shape
What results are most important?
Number 1-5
  • Increase Strength
  • Increase Muscle Size
  • Improve Definition
  • Improve Self Esteem
  • Improve Power
Improve My Quality of Life
What results are most important?
Number 1-5
  • Improve Fitness/Health
  • Increase Energy & Endurance
  • Improve Mobility
  • Improve Flexibility
  • Sleep Better
13.
On a scale of 1 to 10, how important is it to achieve these results?
1
2
3
4
5
6
7
8
9
10
Not Concerned
Need More Info
Very Keen
Urgent/Very Important
14.
How many days / week could you invest time with your PT to ensure your results?
1
2
3
4
5
I understand that this trainer is not able to provide me with medical advice with regard to my medical fitness. I agree to seek my own medical advice. This information is used to the limitations of my ability to exercise. I will not hold this trainer liable in any way for any injuries that may occur while I am training.
I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
The pain you feel today, will be the strength you feel tomorrow.
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