Scribd
Upload
347 views3 pages

Pre Exercise Screening Form

This document is an exercise pre-screening questionnaire meant to identify any existing medical conditions that could impact physical activity. It collects personal information and asks questions about cardiovascular health, respiratory issues, diabetes, joint or muscle problems, and current medications. If any questions are answered "yes" or the person is unsure, they are advised to get medical clearance before starting an exercise program. The form also includes optional sections on family history, lifestyle factors, goals, and a basic fitness assessment.

Uploaded by

Yunon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
347 views3 pages

Pre Exercise Screening Form

This document is an exercise pre-screening questionnaire meant to identify any existing medical conditions that could impact physical activity. It collects personal information and asks questions about cardiovascular health, respiratory issues, diabetes, joint or muscle problems, and current medications. If any questions are answered "yes" or the person is unsure, they are advised to get medical clearance before starting an exercise program. The form also includes optional sections on family history, lifestyle factors, goals, and a basic fitness assessment.

Uploaded by

Yunon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

Exercise Pre-Screening Questionnaire

This is to be completed in preparation for physical activity. It is important that you disclose ALL of
you existing medical conditions so that we/I may determine whether to seek further medical advice
before commencing an exercise program. This questionnaire does not provide medical advice in any
form and does not substitute advice from appropriately qualified professionals.

Title: Name: Surname:


Address: Postcode:
Contact Number: DOB: Age: Email:
Emergency Contact Name: Number:
Yes No
Part One:
Have you ever been told that you have a heart condition?

Have you ever had a stroke? Yes No

Do you ever have unexplained pains in your chest at rest or during physical Yes No
exercise?

Do you consistently feel faint or suffer from spells of dizziness? Yes No

Do you suffer from asthma and require medication? Yes No

Do you suffer from type I or II diabetes? Yes No

Do you suffer from any major muscle or joint conditions that may limit you or be Yes No
aggravated by physical activity?

Do you suffer from any medical conditions that may be made worse by participating Yes No
in physical activity?

Do you suffer from high blood pressure over 140/90 or low blood pressure below Yes No
100/80?

Disclaimer:
If you have answered no to all of the above questions and you are confident that you have no other concerns with your
health then you may proceed to participate in physical activity. If you have answered yes to any of the questions above
or are unsure, please seek a referral from your GP or allied health professional before commencing physical activity.

I believe to the best of my knowledge that all of the information I have provided on this tool is accurate. In the case that
my medical condition changes over the course of my training I will inform my trainer and fill out a new exercise pre-
screening questionnaire.

Client signature: Trainer signature:


Date: Date:
Part Two (Optional)
Do you have a family history of heart disease? (stroke, heart attack) Yes No

Have you been told that you have high cholesterol? Yes No

Have you been told that you have high blood sugar? Yes No

Have you spent time in hospital for any medical condition/illness/injury Yes No
during the last 12 months?

If yes to any of the above, please give details:

Do you smoke? If so how many cigarettes per day/week?

Are you currently on any medication? Yes No


If yes what is it and for what condition?

Are you pregnant or have you given birth in the past 12 months? Yes No
If yes provide details on how many months and any related conditions

What are your top five health and fitness goals for the next 12 months?

Disclaimer:
If you have answered no to all of the above questions and you are confident that you have no other concerns with your
health then you may proceed to participate in physical activity. If you have answered yes to any of the questions above
or are unsure, please seek a referral from your GP or allied health professional before commencing physical activity.

I believe to the best of my knowledge that all of the information I have provided on this tool is accurate. In the case that
my medical condition changes over the course of my training I will inform my trainer and fill out a new exercise pre-
screening questionnaire.

Client signature: Trainer signature:


Date: Date:
Fitness Assessment Tool
Client Name:

Date:

Blood
Pressure:

Weight

Measurements

Shoulders

Chest

Waist (Navel)

Hips (Mid
Butt)

Left Right Left Right Left Right Left Right Left Right Left Right
Thigh
(Thumb)

Arm (Flexed)

Fitness Test
(Optional)
60 second
squats
60 second
push ups
60 second
shuttle runs
It is also a good idea to do before and after photos of your clients only if this is something that they
are comfortable doing.
Notes:

You might also like