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ADULT PRE-EXERCISE SCREENING TOOLThis screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualifiedmedical professional- No warranty of safety should result from its use. The screening system in no way guarantees against injury ordeath. No responsibility or liability whatsoever can be accepted by Exercise and Sports Science Australia, Fitness Australia or SportsMedicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained inthis tool.
Name:
Date of Birth: Male Female Date:
STAGE 1 (COMPULSORY)AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may beat a higher risk ofan adverse event during physical activity/exercise. This stage is self administered and self evaluated.
Please circle response
1. Has your doctor ever told you that you have a heart condition or have
you ever suffered a stroke?
2. Do you ever experience unexplained pains in your chest at rest or
during physical activity/exercise?
3. Do you ever feel faint or have spells of dizziness during physical
activity/exercise that causes you to lose balance?
Yes
Yes
Yes
4.
5.
6.
7.
Have you had an asthma attack requiring immediate medical
attention at any time over the fast 12 months?
If you have diabetes (type I or type II) have you had trouble
controlling your blood glucose in the last 3 months?
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?
Do you have any other medical condition(s) that may make it
dangerous for you to participate in physical activity/exercise?
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
Yes
Yes
Yes
Yes
No
No
No
believe that to the bestof my knowledge, all of the information I have supplied within this tool is correct
Signature ^ ^ H. Date J2. 1
Fitness AustraliaBCHICBE ft WOKIS BOENCE AUSTRALIA
SPORTSMEDICINE
AUSTRALIAVI (2011) PAGE!
ADULT PRE-EXERCISE SCREENING TOOLSTAGE 2 (OPTIONAL)
Name:
Date of Birth: Date:
AIM: To identify those individuals with risk factors or other conditions to assist with appropriate exercise prescription.This stage is to be administered by a qualified exercise professional.
RISK FACTORS
1. Age 3?
Gender
2. Family history of heart disease (eg: stroke, heart
attack)Relative
I — I Father
CD Brother
_| Son
Age Relative
1 — I Mother
l~~l Sister
__] Daughter
Age
> 45yrs Males or > 55yrs Females+1 risk factor
lfmale<55yrs =+1 riskfactor
If female < 65yrs =+1 riskfactor
Maximum of 1 risk factor for this
question0
3. Do you smoke cigarettes on a daily or weekly basis or if yes, {smoke regularly or
have you quit smoking in the last 6 months? Yes f NoJ given up within the past 6 months)
,r =+1 riskfactorIf currently smoking, how many per
day or week?
4. Describe your current physical activity/exercise levels
Sedentary Light Moderate Vigorous
D DFrequencysessions per week
Durationminutes pet week
5. Please state your height (cm) I^D
&>{ Wt weight (kg) g$
6. Have you been toldjjiat you have high blood
pressure? Yes (No,
7. Have yoy^been told that you have high cholesterol?
Yes /Nol
8. Have you been told that you have high blood
sugar? Yes
If physical activity level
< 150 min/ week - +1 risk factor
If physical activity level
> 150 min/ week = -1 risk factor
(vigorous physical activity/exercise
weighted x 2)
Tofdl ^
BMI=BMI > 30 kg/m^ = +1 riskfactor
lfyes, = +1 riskfactor
lfyes,-+1 riskfactor
If yes, = +1 riskfactor
q•6
o-o
Note: Refer over page for risk stratification. STAGE 2 Total Risk Factors = /
"
V1 (2011) PAGES
9. Have you spent time in hospital (including day admission) for If yes, provide detailsany medical condition/illness/injury during the last 12 months?Yes
10. Are you currently taking a prescribed medication(s)for any medical conditions(s)? Yes /N63)
If yes, what is the medical condition(s)?
11. Are you pregnant or have yougiven birth withinthe last 12 months? Yes
If yes, provide details. I ammonths pregnant or postnatal (circle).
12. Do you have any muscle, bone or joint pain or sorepe&s that is If yes, provide detailsmade worse by particular types of activity? Yes (No )
^—i*'
STAGE 3 (OPTIONAL)AIM:To obtain pre-exercise baseline measurements of other recognised cardiovascular and metabolic risk factors. Thisstage is to be administered by a qualified exercise professional. (Measures ],2&3- minimum qualification, CertificateIII in Fitness; Measures 4 and 5 minimum level. Exercise Physiologist*).
1. BMI(kg/m2)
2. Waist girth (cm)
3. Resting BP(mmHg)
4. Fasting lipid profile"
Total cholesterol
HDL
Triglycerides
LDL
5 Fastjrfg blood glucose*
Total stage 2
or
Total stage 3Pius stage 2 (Q1 - Q4)
RESULTS
BM1 > 30 kg/m? - +1 risk factor
Waist > 94 cm for men an<
> 80 cm for women^T risk factor
SBP >14f>mrnHg or DBP >90 mmHg
= i fisk factor
Total cholesterol > 5.20 mmol/L = +1 risk factor
HDL cholesterol >1.55 mmol/L = -1 risk factor
HDL cholesterol < 1.00 mmol/L = +1 risk factor
Triglycerides > 1.70 mmol/L = +1 risk factor
LDL cholesterol > 3.40 mmol/L = +1 risk factor
Fasting glucose> 5.50mmol = +1 risk factor
STAGE 3 Total Risk Factors =
RISK STRATIFICATION
> 2 RISK FACTORS - MODERATE RISKCLIENTS
Individuals at moderate risk may participate in aerobicphysical activity/exercise at a light or moderate intensity(Refer to the exercis.ejntensity table on page 2)
<^2mSK FACTORS - LOW RISKCUENJ^)
Individuals at low risk may participate in aerobic physicactivity/exercise up to a vigorous or high intensity{Refer to the exercise intensity table on pdyt 2)
Note: If stages is completed, identified risk factors from stage 2 (Q1-4) and stage 3 should be combined to indicate risk. If there are extreme or multiple risk factors, theexercise professionaf should use professional judgement to decide whether further medical advice is required.
VI (2011) PAGE 4
•
AUSTRALIANINSTITUTEOF FITNESS*
FIRST IN FITNESSCOURSES & CAREERS
Personal Profile "tell us about you"We want to help you! Please take a few minutes to provide us with some personal information. You can answerthe questions yourself or work through these with your instructor.
Your SurnameYour First Name
Your Address
Mobile Phone
Your Email
Emergency Contact Name
Your occupation
Postcode
Work Phone
Your DOB
Their phone.
Todays Date lO - O I
Health and Fitness GoalsWhat do you hope to achieve from your exercise program? Please circle the number which best represents
the importance of this goal where 1 = extremely important, 3 = somewhat important and 5 = not important.
I need to get fitter
I need to get stronger
I need more energy
I want more muscle
I want muscle definition
I want to lose weight
I need to get more flexible
My number 1 goal right now is
I would like to achieve this goal by
Why is this goal so important to you?
Are there any reasons why you can't achieve this goal?
About You
Are you currently exercising or playing sport? If so, please describe how often and how hard this activity is.
Other important goalsT^
i (
Which statement describes you the best when it comes to exercise (please tick)
Self-motivated LI Prefer a training partner^^T Need regular help U Tend to lose motivation
In 1 -2 words, describe your current health, fitness and body shape? bo
Let's be more specific now - circle the number below to describe how you are feeling at the moment.1
How ENERGETIC are you?
1 2 3 4 5 6 7 8
I just want to sleep& 10
I am the energizer bunny
How HEALTHY do you feel?
1 2 3 4j am always sick
10at's a Doctor?
How FIT do you feel?
1 2 3 4I get puffed looking at the stairs
How STRONG do you feel?
1 2 3 4I need help to carry my groceries
6~&€ '
9 1 0 *I can run the stairs while talking
*fr9 10
I can lift my own bodyweight
Lifestyle ReviewHow much time can you dedicate to an exercise program? 7 days/week J^ minutes/day h^r^l^QJc.^
What time of the day can you exercise - Early mornings G Mornings G Afternoons G Evenings 01 /K^>r-
What types of exercise/activities interest you (please tick) G ~~w "V »
G Walking G Stationary cycling G Swimming (^-'Weight machines G Stretching
\a Running G Rowing machine G Cross trainer G^ree weights^, Q^Sport
G Group exercise classes e.g.,
Are you following a particular eating plan or currently on a diet?
Would you like guidance with your current eating patterns?
Other?
What changes are you prepared to make to achieve your goals?
Health Check
Your resting HR is: _ ^^ bpm Your HR rating is:
Your resting BP is: ' / "^ mmHg Your BP rating is:9&
Your waist measure is: ° cm Your hip measure is:
0-1-9Your W/H ratio is:_ 7 ' cm Your W/H rating is: _
cm
Do you have any other conditions or concerns not identified in the Pre-exercise Screening questionnaire?
#/
Agreement for Participating in Exercise
• I acknowledge that it is a condition of participating in exercise that I do so at my own risk• I accept all risks and hereby indemnify and release the instructor, their agents, affiliates, employees, members,sponsors, promoters and any person or body directly and indirectly associated with the Trainer, against all liability(including liability for their negligence and the negligence of others) claims, demands, and proceeding arising out of orconnected with my participation in this exercise• I acknowledge that participating in exercise may involve a risk of serious injury or even death from various causesincluding: over exertion, dehydration, equipment failure and accidents with equipment and surroundings• I recognise the difficulties associated with the activity and attest I am physically fit to participate safely in the activity andthat a qualified medical practitioner has not advised me otherwise• I understand the demanding physical nature of exercise. I am not aware of any medical condition, injury or impairmentthat will be detrimental to my health if I participate in exercise. In the event that I become aware of any medicalcondition, injury or impairment that may be detrimental to my health, the instructor will be immediately informed. Bycontinuing to participate in this exercise, I accept the risks despite these conditions and am still, and will always be underthe terms of this agreement.• I certify that I am 18 years or older and have read this document and fully understand it OR as a parent or guardian ofthe participant (a) laaree^tti the above for myself and on behalf of the participant and (b) I indemnify and will keepindemnified any (JeTspng^bQciiulifectly or indirectly associated with the conduct of the exercise on the terms referred to.
(guardian/parent to sjgn if under 18 years of age)
301Signature:
Full name (please~prTnt):
Instructor's Name:
Date:
Instructor's Signature:
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