Strength & Conditioning pre-exercise screening

The health benefits of regular activity are clear. More people should engage in physical activity as often as possible. Participating in physical activity is very safe for MOST people. The goal of this screening is to identify individuals who may be at a higher risk of an adverse event during our Strength & Conditioning sessions. This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualifies medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury.

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Name
Sexe
Date of Birth
Address
Emergency Contact
General Health Questions
Do you have a spinal cord injury?
This includes tetraplegia and paraplegia
Do you have a known heart condition or ever suffered a stroke?
Do you ever experience unexplained pains in your chest at rest or during physical activity?
Do you ever feel faint or have spells of dizziness during physical activity that causes you to loose balance?
Have you ever had an asthma attack requiring immediate medical attention at any time during the last 12 months?
If you have diabetes (type I or II) have you had trouble controlling your blood glucose in the last 3 months?
Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in a physical activity?
Do you have any other medical condition(s) that may make it dangerous for you to participate in any physical activity?
If you answered NO to all of the questions above, we will be happy to see you during our strength and Conditioning Sessions! Please go directly to the end of the form.
If you answered YES to one or more questions above, please complete the form below, we'd like to know more about you:
1. Do you have Arthritis, Osteoporosis or Back Problems?
Do you control your condition with medication or therapy? Do you have joint problems causing pain? recent fracture?
2. Do you have a heart or cardiovascular condition?
This includes Coronary artery disease, heart failure and/ or diagnosed abnormality of heart rhythm.
Do you control your condition with medication or therapy? Do you have an irregular heart beat that required medical management? Do you have chronic heart failure?
3. Do you have any metabolic conditions?
This includes Type I diabetes, Type II diabetes, Pre-diabetes
Do you often suffer from signs of low blood sugar (hypoglycemia) following exercise? Do you have any signs of diabetes complications such as heart disease? Do you have any other metabolic conditions?
4. Do you have a respiratory disease?
This includes Chronic Obstructive Pulmonary disease, Asthma, Pulmonary high blood pressure.
Do you control your condition with medication or therapy? If asthmatic, do you use any medication?
5.1. Do you have difficulty controlling your condition with medications or other therapies?
5.2. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness and/ or fainting?
5.3. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?
6. Do you have any other medical condition not listed above?
Such as epilepsy, neurological conditions, kidney problems...
Participant Declaration
Please understand that it is advised that you consult a qualified professional regarding your condition. Please keep us updated on any change in your condition or medication.
By ticking this box you:
- Acknowledge that the information provided regarding your health are, to the best of your knowledge, correct. You'll inform Parafed Auckland if there are any changes to your health status. - Acknowledge that participating in physical activity carries a risk and you accept all responsibility for that risk.