ADULT PRE-EXERCISE SCREENING TOOL

Name*

Date of Birth*

Gender*

Male
Female

Mobile*

Email*

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 or death. No responsibility or liability whatsoever can be accepted by World Gym, Exercise and Sports Science Australia, Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.

STAGE 1

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 cause 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 for 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 professional prior to undertaking physical activity/exercise

IF YOU ANSWERED ''NO'' to all the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise.

CONSENT

I hereby acknowledge that by signing: • The information provided above my health is to the best of my knowledge correct. • I will inform you immediately if there are any changes to the information provided above.

ENTER FULL NAME

Signature

World Gym Burpengary | 159-161 Station Road, Burpengary Q 4505 | P 3053 3170 | E: reception@worldgymburpengary.com.au

MC Consultant*