Back "*" indicates required fields PRE-EXERCISE SCREENING SYSTEM FOR YOUNG PEOPLEPARENT TOOL (PSS-PARENT)Important Information: This tool is part of the Pre-Exercise Screening System (PSS) and should be used in conjunction with the PSS User Guide which covers how to use the information collected and to address the aims of each stage. This does not constitute medical advice. These guidelines and the PSS (together ‘the material’) is not intended for use to diagnose, treat, cure or prevent any medical conditions, is not intended to be professional advice and is not a substitute for independent health professional advice. Exercise & Sport Science Australia, Fitness Australia, Sports Medicine Australia and Exercise is Medicine (together ‘the organisations’) do not accept liability for any claims, howsoever described, for loss, damage and/or injury in connection with the use of any of the material, or any reliance on the information therein. While care has been taken to ensure the information contained in the material is accurate at the date of publication, the organisations do not warrant its accuracy. No warranties (including but not limited to warranties as to safety) and no guarantees against injury or death are given by the organisations in connection with the use or reliance on the material. If you intend to take any action or inaction based on the guidelines and/or the PSS, it is recommended that you obtain your own professional advice based on your specific circumstances.Child/Young Person’s Details:Full Name* Full Name Date of Birth* DD slash MM slash YYYY Age*Gender* Male Female Prefer not to say Other Pre-exercise screening results will be kept as confidential files and shared only among individuals involved in the event of urgent medical care, and/or with the consent of the young person and/or parent/guardian.STAGE 1 (COMPULSORY)To be individual completed with a parent/guardian in conjunction with an exercise professional or the individual who is responsible for the medical care of the young person.These questions are part of a screening system designed for young people participating in exercise. The aim is to identify any young person with medical conditions or warning signs that may put them at a higher risk of an unwanted event during activity or exercise sessions. Unwanted events may include something unexpected during exercise leading to illness, physical harm or death. Definition of Child: Any young person between the age of 5-15 years old in your careDoes your child have, or previously had: (Please tick your response)1. A heart condition?* YES DON’T KNOW NO 2. A close relative who has died suddenly from a heart condition before the age of 50?* YES DON’T KNOW NO 3. Uncontrolled epilepsy or seizures/convulsions?* YES DON’T KNOW NO 4. Fainting or dizzy spells with physical activity/exercise?* YES DON’T KNOW NO 5. Diabetes?* YES DON’T KNOW NO 6. An asthma attack requiring immediate medical attention at any time over the last 12 months?* YES DON’T KNOW NO 7. Anaphylactic reactions?* YES DON’T KNOW NO 8. Surgery in the last month?* YES DON’T KNOW NO 9. Any other conditions that may require special consideration for your child to exercise?* YES DON’T KNOW NO IF YOU ANSWERED ‘YES’ or ‘DON’T KNOW’ to any of the 9 questions above, please discuss with the exercise leader or the person administering this form prior to undertaking exercise.IF YOU ANSWERED ‘NO’ we recommend you proceed to Stage 2 with the exercise leader or those providing medical care for the young person.10. Over the past seven days, on how many days was your child physically active for a total of 60 minutes or more per day?*Number of days:To the best of my knowledge, all of the information supplied within this tool is correct. I will inform the exercise leader or those providing medical care for the young person if there are any changes to the information provided.* Parent/Guardian - I hereby acknowledge that:To the best of my knowledge, all of the information supplied within this tool is correct. I will inform the exercise leader or those providing medical care for the young person if there are any changes to the information provided.Name:*Signature:*Date:* MM slash DD slash YYYY 24-hour Physical Activity GuidelinesFollowing these guidelines may be challenging at times; however, meeting them will benefit health. Achieving these guidelines is associated with better health and leads to improved body composition, cardiorespiratory and musculoskeletal fitness, cardiovascular and metabolic health, academic achievement and cognition, and improved mental health and emotional regulation. For those not currently meeting these guidelines, a progressive adjustment towards them is recommended. Figure 1. 24-hour physical activity guidelines (http://www.health.gov.au/internet/main/publishing.nsf/Content/health-24-hours-phys-act-guidelines) SLEEP 5-13 yr olds = 9-11 hours per night 14-17 yr olds = 8-10 hours per nightPHYSICAL ACTIVITY Aim for 60 mins or more per day – the more you huff & puff the better!INACTIVITY Move more & sit less in your free timeSTAGE 2 (RECOMMENDED)This stage is to be completed with an activity or exercise leader, or a relevant health professional, to highlight possible medical conditions or warning signs that may put a child/young person at a higher risk of an unwanted event during activity or exercise sessions.11. Does your child take any regular medications or supplements?* YES NO If your child is taking any regular medications or supplements, provide details:12. Does your child have any current health or medical management plans (e.g. anaphylaxis, asthma or diabetes)?* YES NO If yes, provide details:Anaphylaxis - Epipen?* YES NO NA Diabetes - insulin or glucose?* YES NO NA Asthma - reliever (Ventolin or other)?* YES NO NA 13. Has your child experienced heat related illness previously?* YES NO If yes, provide details:14. Has your child spent time in hospital (including day admission) for any medical condition/ illness/ injury during the last 12 months?* YES NO If yes, provide details:15. Does your child have any muscle, bone or joint problems and/or pain that could be made worse by participating in activity?* YES NO If yes, provide details:16. In the last month has your child suffered an episode of concussion?* YES NO If yes, provide details:17. Which of the following behaviours did your child do in the last 7 days?Sport (including training)* Yes No FrequencyDuration (average)Physical Education class* Yes No FrequencyDuration (average)School physical activity (e.g. fitness, lunch time sports)* Yes No FrequencyDuration (average)Active travel (e.g. walk or cycle to shops/school)* Yes No FrequencyDuration (average)Other physical activity (e.g. gym, walking the dog, play at playground)* Yes No Duration (average)FrequencyOver the last week, what time did your child go to bed (Sunday to Thursday evening)?Over the last week, what time did your child wake up (Monday to Friday morning)?On the weekend (Friday or Saturday evening), what time did your child go to bed?On the weekend (Saturday or Sunday morning), what time did your child wake up?On the last 5 school days (Monday to Friday), how much time on average did your child spend:Watching movies or TV shows on any device (TV, computer, tablet or smartphone?)HoursSurfing the internet for fun?HoursTexting or messaging, or using social media?HoursPlaying videogames on smartphones, computers, tablets or consoles like Playstation?Hours*OPTIONAL*18. Is your child pregnant or have they given birth previously? YES NO If yes, provide details:
