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: