Pre-Exercise Medical and Health Screen

HEALTH AND WELLNESS COACH

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Pre-Exercise Medical and Health Screen

Prior to commencing any exercise program you must complete a Pre-Exercise Screen in order to assess your suitability to exercise and to assist Sharyn Cahill with providing you with correct exercise instruction.
Note: This per exercise medical and health screen is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the
seven questions.

Name *

First

Last

Contact Number *

Email *

Date of Birth *

Emergency Contact - Name *

First

Last

Emergency Contact - Number *

Has your doctor ever told you that you have a heart condition or ever suffered a stroke? *

Do you experience unexplained pains in your chest at rest or during physical activity/exercise? *

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? *

Have you had an asthma attack requiring immediate medical attention at any time in the last 12 months? *

If you have diabetes (type 1 or type 2) have you had trouble controlling your blood glucose in the last 3 months? *

Do 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 makes it dangerous for you to participate in physical activity/exercise? *

If you answered YES to any of the above 7 questions, your Health and Fitness instructor will clarify any further information and may recommend you to seek guidance from your GP or allied health professional prior to undertaking physical activity/exercise. If you answered NO to all 7 questions, and you have no other concerns about your health, please proceed to undertake light-moderate intensity exercise.

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