LET’S WORK Enter your details to activate your PLAN and start achieving your goals. Name* First NameLast Name Email* example@example.com Back Next Client Form Gender* FemaleMaleOther Date Of Birth* -Month -DayYear2 digit month, 2 digit day, 4 digit yearDate Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Occupation (This information helps gauge your activity level outside of planned exercise including unpaid work and study)* Emergency Contact Name* Relationship* Phone Number* Please enter a valid phone number.Format: (000) 000-0000. General Practitioner's Name* General Practitioner's Phone* Please enter a valid phone number.Format: (000) 000-0000. General Practitioner's Clinic Name* General Practitioner's Clinic Address* Would you like to include any of the following methods to help track your progress? (Please select all that apply) This is optional, but it can offer valuable insights into your journey.* Circumference measurements (guide available)Progress pictures (guide available)Body weight (guide available)Calories - MyFitnessPal Free version (guide available)Steps (guide available)None What days do you prefer to train on?* Where do you prefer to train?* GymHome Please list at-home equipment:* Have you followed any fitness plans before?* YesNo If yes, please list below:* Have you followed any diets before?* YesNo If yes, please list below:* Please note any suggestion or personal considerations you may have in working with me.* Back Next Pre-Exercise Screening Questionnaire This questionnaire is designed to help assess an adult’s readiness for physical activity and identify potential risks prior to beginning an exercise program.The questions are informed by standard pre-exercise screening guidelines, including those outlined in the Adult Pre-Exercise Screening System (APSS). Important: This form is for informational purposes only and does not replace professional medical advice. Participants should consult a qualified healthcare professional before starting or changing any exercise program. Q1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?* YesNo Q2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?* YesNo Q3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?* YesNo Q4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?* YesNo Q5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose)in the last 3 months?* YesNo Q6. Do you have any other conditions that may require special consideration for you to exercise?* YesNo IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise. IF YOU ANSWERED ‘NO’ to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/exercise per week. Once you have completed and submitted this form, if your responses indicate that a referral may be appropriate, I can assist you through the referral process. I will help connect you with a suitable allied health professional or medical practitioner to ensure you can safely undertake exercise. Q7. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. Intensity* Rows Light Moderate Vigorous/High Frequency (number of sessions per week) Duration (total minutes per week) If your total is less than 150 minutes per week then light to moderate intensity exercise is recommended. Increase your volume and intensity slowly. • If your total is more than or equal to 150 minutes per week then continue with your current physical activity/exercise intensity levels. • It is advised that you discuss any progression (volume, intensity, duration, modality) with an exercise professional to optimise your results. Weighted physical activity/exercise per week* Total minutes = (minutes of light + moderate) +(2 x minutes of vigorous/high) Q8. Family history of heart disease (e.g. stroke, heart attack)?* A family history of heart disease refers to an event that occurs in relatives including parents, grandparents, uncles and/or aunts before the age of 55 years. Q9. Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?* YesNo If currently smoking, how many per day or week?* Smoking, even on a weekly basis, substantially increases risk for premature death and disability. The negative effects are still present up to at least 6 months post quitting. Q10. Body composition Any of the below increases the risk of chronic diseases: BMI ≥ 30 kg/m2 Waist > 94 cm male or > 80 cm female Weight (kg)* Height(cm)* Body Mass Index (kg/m2) Waist circumference (cm) Q11. Have you been told that you have high blood pressure?* YesNo Either of the below increases the risk of heart disease: Systolic blood pressure ≥ 140 mmHg Diastolic blood pressure ≥ 90 mmHg If known, systolic/diastolic (mmHg)* Are you taking any medication for this condition?* YesNo If yes, provide details* Q12. Have you been told that you have high cholesterol/blood lipids?* YesNo Any of the below increases the risk of heart disease: Total cholesterol ≥ 5.2 mmol/L HDL < 1.0 mmol/L LDL ≥ 3.4 mmol/L Triglycerides ≥ 1.7 mmol/L If known: Total cholesterol (mmol/L) If known: HDL (mmol/L) If known: LDL (mmol/L) If known: Triglycerides (mmol/L) Are you taking any medication for this condition?* YesNo If yes, provide details* Q13. Have you been told that you have high blood sugar(glucose)?* YesNo Fasting blood sugar (glucose) ≥ 5.5 mmol/L increases the risk of diabetes. If known:Fasting blood glucose (mmol/L) Are you taking any medication for this condition?* YesNo If yes, provide details Q14. Are you currently taking prescribed medication(s)for any condition(s)? These are additional to those already provided.* YesNo Taking medication indicates a medically diagnosed problem. Judgment is required when taking medication information into account for determining appropriate exercise prescription because it is common for clients to list ‘medications’ that include contraceptive pills, vitamin supplements and other non-pharmaceutical tablets. Exercise professionals are not expected to have an exhaustive understanding of medications. Therefore, it may be important to use common language to describe what medical conditions the drugs are prescribed for. If yes, what are the medical conditions? Q15. Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?* YesNo There are positive relationships between illness rates and death versus the number and length of hospital admissions in the previous 12 months. This includes admissions for heart disease, lung disease (e.g., Chronic Obstructive Pulmonary Disease (COPD) and asthma), dementia, hip fractures, infectious episodes and inflammatory bowel disease. Admissions are also correlated to ‘poor health’ status and negative health behaviours such as smoking, alcohol consumption and poor diet patterns. If yes, provide details Q16. Are you pregnant or have you given birth within the last 12 months?* YesNo During pregnancy and after recent childbirth are times to be more cautious with exercise. Appropriate exercise prescription results in improved health to mother and baby. However, joints gradually loosen to prepare for birth and may lead to an increased risk of injury especially in the pelvic joints. Activities involving jumping, frequent changes of direction and excessive stretching should be avoided, as should jerky ballistic movements. Guidelines/fact sheets can be found here: 1) www.exerciseismedicine.com.au 2) www.fitness.org.au/Pre-and-Post-Natal-Exercise-Guidelines If yes, provide details Q17. Do you have any diagnosed muscle, bone, tendon,ligament or joint problems that you have been told could be made worse by participating in exercise?* YesNo Almost everyone has experienced some level of soreness following unaccustomed exercise or activity but this is not really what this question is designed to identify. Soreness due to unaccustomed activity is not the same as pain in the joint, muscle or bone. Pain is more extreme and may represent an injury, serious inflammatory episode or infection. If it is an acute injury then it is possible that further medical guidance may be required. If yes, provide details I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.* Yes Date* -Month -DayYear2 digit month, 2 digit day, 4 digit yearDate Signature* SubmitSubmit Should be Empty:
