EXERCISE READINESS QUESTIONNAIRE
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- Allison Porter
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1 EXERCISE READINESS QUESTIONNAIRE A little bit about yourself... First Name Surname Address Postcode Best Contact Phone No. Your Birthday Today s Date Occupation Emergency Contact Phone Number About your health and fitness goals... I need to get fitter I need to look my absolute best for a specific occasion I need to lose weight I need to improve my self confidence I need to build muscle I want to feel better about my body I need more energy I have a specific sporting goal I need to get stronger I need a healthy eating plan and some Guidance I need to rehabilitate (please specify)
2 I have another very important goal that I would like to achieve and it is to Why is it important to you to make these changes and achieve these goals? When would you like to have made these changes and achieved your goal by? Will you achieve your goals if continue to repeat your past and current lifestyle patterns? What has held you back from achieving your goals in the past? Procrastination Tight Budget No Time Injury Lack of Support Confused Other? Is this still a challenge for you? Do you currently exercise on a regular basis? How many days per week do you exercise? Describe to me what exercise program you currently follow or have done in the past Are there any exercises you do not like? How do you rate your current health and exercise? How ENERGETIC do you feel on a daily basis? I just want to sleep I am the Flash How HEALTHY do you feel on a regular basis? Put me down W Doctor, What s a Doctor? I am always SICK!
3 How FIT do you feel on a regular basis? I get puffed looking at the stairs I am Unstoppable How STRONG do you feel on a regular basis? I need help to open the car door I have the Strength to do anything How ACTIVE are you on a regular basis Not at all 3 x week I exercise every day without fail Write one or two words to describe how you feel about your health, wellbeing and body shape at the moment? Write one or two words to describe how you would like to feel about your health, wellbeing and body shape in the future? List 3 foods that you enjoy List 3 foods that you do not enjoy Would you like help/advice with your current eating plans?
4 Medical Screening Do you currently have any medical conditions that may prevent you from exercising? Have you ever had: A Heart Attack Heart Surgery A Pace Maker Heart Failure Heart Valve Disease A Heart Transplant Congenital Heart Disease Symptoms - Do you ever experience: Chest discomfort with exertion Unreasonable breathlessness Dizziness, fainting, blackouts Musculoskeletal problems Other Health items: Do you take prescription medications Take heart medications Are you pregnant Are you trying to conceive If you marked to any of the questions in this section you may need to visit an allied health professional or medical practitioner before commencing an exercise program Cardiovascular Risk Are you male, over 45 Are you postmenopausal Do you smoke Have BP > 140/90 mmhg Take BP medication Have high cholesterol Have family history of heart attack Are you diabetic Have you high blood sugar Have Epilepsy Have Asthma If you marked to two or more questions in this section you may need to visit an allied health professional or medical practitioner before commencing an exercise program If you did not, then that s fantastic! You are in good health and ready to get moving towards your goals immediately! Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity? If yes, please tell me more about it How many standard drinks of alcohol would you consume in a week?
5 I hereby state that I have read, understood and answered honestly the screening questionnaire. During the exercise programme, every effort is made to keep the session safe and minimise the risks while providing an effective session. I am participating of my own free will and I am aware, as with any exercise programme there is a risk of injury. I agree to participate in the exercise programme described to me by Samantha and I understand that in order for the session to remain safe, alternatives and adaptations will be made throughout. I will inform Samantha if any changes occur which may prevent me from exercising safely. If at any time you feel undue pain or excessive discomfort, STOP the activity and inform Samantha. I attest I am physically fit to participate safely in exercise and that a medical practitioner has not advised me otherwise. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in these sessions. Clients Name: Signed: Date: Instructor: Samantha Ferguson Signed: Date:
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