Pre-Exercise Screening Form

Name *
Name
Date of Birth *
Date of Birth
Please list any current or past injuries you have experienced
1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? *
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise? *
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? *
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *
5. If you have diabetes (type 1 or type II) have you had trouble controlling your blood glucose in the last 3 months? *
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? *
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? *
I have answered the above questions honestly and to the best of my ability