Pre-exercise Questionnaire NCC

Gender*

AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This stage is self-administered and self-evaluated.

Please indicate Yes or No to below questions.

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 I 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?*

IF YOU ANSWERED ‘YES’ to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.

IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise

Referred for GP approval

Please supply a copy of your medical clearance, if applicable.

Declaration - I believe that to the best of my knowledge, all of the information I have supplied is correct. I will notify staff if any of the above changes at any time, to assist with my exercise program and safety.*
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