1
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.
www. ip ower pt .com
2
NUTRITION PROFILE QUESTIONNAIRE
This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. The screening system provides no guarantee or assurances that through nutrition counseling wellness goals, losing weight, or overcoming or avoiding health issues will be achieved. No responsibility or liability whatsoever can be accepted by trainer for any harm that may arise from acting on any statement or information contained in this tool.
Stage 1(Compulsory )
1.
WHY do you eat?
Hunger
Boredom
Emotion
Habit
Social
Forced to
Other
How often do you eat?
Daily Water intake?
Daily Caffeine Intake?
Daily Alcohol Intake?
2.
Do you have any known Allergies / Intolerances to foods?
Yes
No
3.
Are you currently on any specific diet:
Vegan
Vegetarian
Paleo
Gluten Free
If yes, why are you following this particular diet?
Trainers advice
Personal Research
Media Recommendation
4.
Do you know how many calories you eat each day?
Yes
No
If yes how many?
5.
Do you take any Vitamins or Dietary Supplements?
Yes
No
6.
How many meals do you prepare at home?
How many times do you buy your meals?
What ?
7.
During your working week - Do you usually
Eat fast food
Make and bring you own food
Eat at restaurants
8.
How many days do you eat out per week?
1
2
3
4
5
6
7
Stage 2(Compulsory )
9.
How many times a day do you eat, including snacks?
10.
Do you skip meals?
Yes
No
11.
How many glasses of water do you drink each day?
1
2
3
4
5
6
7
8
9
10
12.
Do you drink alcohol?
Yes
No
How many drinks per week?
1
2
3
4
5
6
7
8
9
10+
13.
Do you drink tea or coffee?
Yes
No
How many cups per day?
1
2
3
4
5
6
7
8
9
10+
14.
Rate your energy levels during the day:
Mornings
Low
Medium
High
Afternoon
Low
Medium
High
Evening
Low
Medium
High
15.
List 3 areas of your nutrition you would like to improve:
1.
2.
3.
16.
Write out a typical diet of one day. (A usual day)
Breakfast
Snack
Lunch
Snack
Dinner
Drinks
Other
I assume all responsibility and any risks associated with the nutritional choices that I make. I agree to hold this trainer harmless and release them from any liabilities associated with recommendations and information given by them to me relating to dietary changes or nutritional supplements.
I understand that the nutritional counseling provided is not considered to be medical advice and that I am encouraged to consult with my health care provider.
I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
A HEALTHY AND STRONG OUTSIDE
STARTS FROM THE INSIDE
www. ip ower pt .com
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