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Pre-Exercise Screening Tool

Disclaimer

This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an appropriately qualified medical professional. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Gerons Performance Academy any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.

Name

Date of Birth

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.

1. Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Yes

3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?

Yes

4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?

Yes

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?

Yes

7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?

Yes

8. Additional Notes / Medical History

I believe that to the best of my knowledge, all of the information I have supplied, within this form, is correct.

Signature

Sign Here

Date

Completed the required waivers?

Yes

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Pre-Exercise Screening Tool

Disclaimer

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