Adult 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 YMCA 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 YMCA Canberra 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

Client First Name *

Client Last Name *

Preferred Name

Client Gender *

Date Of Birth *

Medicare Number

Independent Reference Number *

Address *

Mobile Phone *

Alternative Contact Number

Email Address *

Preferred method of contact/confirmation

Name of Regular Doctor *

Doctors Phone *

Emergency Contact First Name *

Emergency Contact Last Name *

Emergency Contacts Relationship to Client *

Emergency Contacts Phone Number *

What services are you accessing through YMCA Canberra? *

Exercise PhysiologyGym MembershipBoth

What is your primary reason for accessing YMCA Canberra's Exercise Physiologists? *

Are you accessing services under any of the following?

NDISDVAMedicare

Do you have private health cover? *

YesNo

Who is your health cover provider?

Do you currently work *

YesNo

Occupation

PART ONE: Medical History

Please be aware that our Members Services Team 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 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. It is your responsibility to inform your Exercise Physiologist of any change in physical condition, e.g. injury, new medication that may require a change in activity involvement.

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? *

YesNo

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

YesNo

Do you ever feel faint, dizzy or lose balance during physical activity/exercise? *

YesNo

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

YesNo

If you have Diabetes (type I or type II) have you had trouble controlling your blood sugar (glucose) levels in the last 3 months? *

YesNo

Do you have any other conditions that may require special consideration to exercise? *

YesNo

Please provide full details of any conditions you ticked yes to above

If you have answered YES to any of the questions above, you are required to seek guidance from an Allied Health Professional (Exercise Physiologist) or medical practitioner. Book in for an Initial Consultation with one of our Exercise Phyiologists before you begin any exercise at The Y Canberra, Chifley Health and Wellness Centre.

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

Other (please specify)

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 YMCA Canberra staff however will be shared with relevant professionals within YMCA Canberra to ensure my saftey and quality of services. I am aware of the limits of confidentiality.

Signature *

Draw signature|Type signatureClear

Name *

Date *

To be reviewed and completed by a Y Canberra Exercise Physiologist:

Medical Clearance Required

YesNo

Seen and Approved

YesNo

Exercise Professional’s Name

Review Date

Exercise Professional's Signature

Draw signature|Type signatureClear