EXERCISE PRE-PARTICIPATION HEALTH SCREENING QUESTIONAIRE Name *Date *Email Address *Contact No. *Step 1SYMPTOMSDoes your client experience:Chest pain/discomfort with exertion *YesNoDifficulty breathing *YesNoDizziness, fainting, blackouts *YesNoAnkle swelling *YesNoUnpleasant awareness of a forceful, rapid or irregular heart rate *YesNoBurning/cramping sensations in your lower legs *YesNo: if you did mark any of the statements under the symptoms, please seek medical clearance before engaging in or resuming exercise. You may need to use a facility with medically qualified staff.If you did not mark any symptoms, continue to steps 2 and 3Step 2CURRENT ACTIVITYDo you currently perform planned, structured physical activity for at least 30 min, at moderate intensity on at least 3 days, per week for at least the last 3 months? *YesNoStep 3MEDICAL CONDITIONSHave you had or currently have *a heart attack diabetesdiabetesheart surgery, cardiac catheterizationhypertensionor coronary angioplastycancerpacemaker/implantable cardiaclung diseasedefibrillator/rhythm disturbancedyslipidaemiaheart valve diseasemetabolic syndromeheart failuredepressioncongenital heart diseasekidney diseaseNone of theseSend Message
