Pre-Activity Questionnaire

In preparation for physical activity, please tell us about ALL of your existing medical and physical conditions, and who to contact in an emergency. It is your responsibility to complete this form before participating in any physical activity. For any conditions that can be affected by exercise, you may be asked to consult your doctor and obtain a written medical clearance to exercise. Please give this clearance to Older Fitter Better. The information contained will be treated as confidential and only revealed to other instructors for your safety.

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

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

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

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

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5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

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6. Do you have any other conditions that may require special considerations for you to exercise?

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IF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE talk to your doctor or phone us BEFORE you start this program.

You may be able to do any activity you want – as long as you start slowly and build up gradually or you may need to restrict your activities to those which are safe for you. Talk to the doctor about the kinds of activities you wish to participate in and follow his/her advise.

IF YOU ANSWERED NO TO ALL QUESTIONS you can be reasonably sure that you can start becoming more physically active – begin slowly and build up gradually.

DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS?
Select YES/NO next to any of the items below

Arthritis

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Asthma

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Diabetes

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Epilepsy

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Osteoporosis

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Heart problems/disease

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High cholesterol

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Stroke

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Family history of heart disease or stroke

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High or low blood pressure

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Any other conditions? Please describe below

DO YOU HAVE, OR HAVE YOU HAD, ANY JOINT PROBLEMS, PAINS OR INJURIES IN ANY OF THE FOLLOWING REGIONS? Select YES/NO next to any of the items below

Shoulders

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Knees

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Hips/pelvis

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Muscular Pain

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Neck

Elbows

Wrists

Lower Back

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Other? Please describe below

ARE YOU CURRENTLY TAKING ANY MEDICATION/S? If YES, please describe

ARE YOU CURRENTLY EXERCISING?
If Yes, What type?

How hard?

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How many times per week?

If you are not currently exercising, have you in the past?

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If Yes, What type?

Name

Pension  No.

Date

Thanks for submitting!