Get Up and Go! Pre-Exercise Screening Questionnaire

Personal information collected in this questionnaire will be managed in accordance with the Y Canberra Region Privacy Policy. Please read our Privacy Policy for information relating to the collection, use and disclosure of your personal and sensitive information. 

By completing this questionnaire, you are deemed to have read and agreed to the Y Canberra Membership Agreement. You also represent and warrant that you are over the age of 18, or if under the age of 18, your parent and/or guardian has completed this questionnaire and the Membership Agreement on your behalf. This screening questionnaire in no way guarantees against any injury or death. No responsibility or liability whatsoever is accepted by the Y Canberra Region for any loss, damage, or injury that may arise from any person acting on any statement or information contained or received in accordance with this questionnaire.

Contact Details


PART ONE: Medical History

Please be aware that our Fitness Instructors have no expertise in the field of medicine nor are they trained to detect serious medical problems. If you have any specific medical concerns, conditions or requirements you are advised to consult your Doctor before participation as to what specific restriction, if any, should apply to your condition and which activities and or exercises you should avoid.  You are solely responsible for evaluating and assessing your own health and wellbeing and whether, in all the circumstances, you should access and use facilities and participate in classes.

If you have answered YES to any of the seven questions above, you are required to seek medical clearance from an appropriate allied health professional or medical practitioner prior to undertaking any exercise. 

Do you or have you suffered from the following diseases or conditions? If yes, please specify details.


PART TWO: Physical Activity

Describe your current physical activity in a typical week by stating the frequency, duration and level of intensity.

Please provide an indication of your goals and preferences 


PART THREE: Assignment and Release

I, the undersigned, certify that I (or my dependent) understand that the information I have given today is correct to the best of my knowledge.  I also understand that this information will be confidential to the Y Canberra Region staff however will be shared with relevant professionals within the Y Canberra Region to ensure my saftey and quality of services. I am aware of the limits of confidentiality. 

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To be reviewed and completed by a the Y Canberra Region exercise professional

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