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


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.

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 


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. 

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

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