Pre-train — Creighton Personal Training

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.

Name

First Name

Last Name

Date of birth

Have you ever been told that you have a heart condition?

Have you ever had a stroke?

Do you ever have unexplained pains in your chest at rest or during physical exercise?

Do you consistently feel faint or suffer from spells of dizziness?

Do you suffer from asthma and require medication?

Do you suffer from type I or II diabetes?

Do you suffer from any major muscle or joint conditions that may limit you or be aggravated by physical activity?

Do you suffer from any medical conditions that may be made worse by participating in physical activity?

Do you suffer from high blood pressure over 140/90 or low blood pressure below 100/80?

If you have answered YES to anything please detail below. If there is anything else you wish to add, please enter below.

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.