PRE-EXERCISE SCREENING QUESTIONNAIRE
PLEASE TICK BOX IF INTERESTED IN OTHER SERVICES
A multidisciplinary approach for allied health services generally results in better outcomes for patient care and goals. Please tick the service(s) you are interested in and we will ensure you are put into contact with an appropriate provider.
Is it broken sleep?
Frequency (how many times a week)
Describe your current weekly physical activity/ exercise levels in a typical week by stating the frequency and duration at different intensities:
Frequency (how often are you physically active)
Intensity (what is the usual intensity of your physical activity)
Duration (how long are you physically active each time)
Type (What type of physical activity are you engaging in eg. Running):
Do you smoke cigarettes on a daily basis or have you quit smoking in the last 6months?
Do you drink alcohol on a daily basis? If yes, how many standard drinks per day?
Do you have diagnosed muscle, bone or joint problems (e.g. osteoarthritis, spondylosis, scoliosis), chronic conditions (e.g. diabetes, heart disease), mental conditions (e.g. ptsd, anxiety, depression)? Please include all accepted conditions.
Do you have any other undiagnosed pain or soreness that is made worse with movement Yes/ No: If yes, Please indicate where you have a pain:
Has your doctor ever told you, you have a heart condition, or have you ever suffered a stroke?
Do you ever experience unexplained pains in your chest at rest or during physical activity?
Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?
Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?
Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?
Do you have a family history (parent, sibling or child) of heart disease?
Have you been told that you have high blood pressure?
Have you been told you have high cholesterol?
Have you been told that you have high blood sugar?
Are you currently taking prescribed medication for any medical conditions? If so, please list them.
Have you spent time in hospital (including day admission) for any medical condition/illness/injury during the last 12 months?
If yes, please explain
Are you pregnant or have you given birth within the last 12 months?
Any further comments
- You authorise ABC to collect, use, store, correct, update, disclose or otherwise process any information including personal information which relates to and/or identifies you, including but not limited to, your name, address, date of birth, employment details, contact details, emergency contact details, Medicare Australia Card information, Department of Veteran Affairs entitlement information, health insurance information, medical history and other information regarding your health and lifestyle decisions (Personal Information), to the extent reasonably necessary for ABC to provide the services you requested from ABC (and/or its contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns) or third parties and also for the purpose of researching, developing and enhancing ABC’s services and/or complying with ABC’s legal obligations;
- You acknowledge and agree that the types of Personal Information which ABC collects will depend on the circumstances of its collection and the nature of your particular dealing with ABC and you further acknowledge and agree that ABC is required to collect certain Personal Information to ensure compliance with its legal obligations or as required by various government agencies (such as the Department of Veteran Affairs and Medicare Australia) or as required by various regulatory bodies (such as Exercise & Sports Science Australia);
- You acknowledge and agree that in some circumstances, Personal Information is provided to ABC by third parties or other organisations conducting activities on your behalf. Such third parties would include for example your medical practitioner or Medicare Australia and it is assumed that you have provided consent for your personal information to be used and disclosed to ABC this way;
- You acknowledge that Personal information ABC has collected from you (including but not limited to the information contained in the above Pre-Exercise Screening Questionnaire) may be transferred to ABC’s contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns or third parties where ABC considers it is necessary to meet the purpose for which you have submitted the Personal Information and you therefore authorise ABC to disclose your Personal Information to any such parties to the extent necessary to perform the services to you or as otherwise required by law or with your consent;
By completing the above Pre-Exercise Screening Questionnaire and signing below, you acknowledge and agree:
- That Active Body Conditioning Pty Ltd (ABC) does not accept responsibility for lost, stolen or damaged valuables, cash or personal items;
- to abide by the rules of and follow any directives of ABC and any facility where ABC provides its services to you (Facility) at all times;
- That you have voluntarily engaged the services of ABC and you are making use of the services ABC provides and accessing and using the Facility of your own free will;
- that you have provided all relevant information regarding your medical history and the current status of your health and any current medical conditions to ABC;
- That all information that you have provided to ABC is complete and accurate to the best of your knowledge;
- That, if relevant, this Pre-Exercise Screening Questionnaire (including this Disclaimer) extends to any hydrotherapy services provided to you by ABC and any reference to ‘Facility’ includes any pool from which ABC provides its hydrotherapy services to you;
- that, if you have provided your credit card details to ABC, you authorise ABC to input those details into its online practice and patient management software (currently Halaxy) on the basis those details will then be stored electronically by its online practice and patient management software to pay future invoices issued to you by or on behalf of ABC for services provided to you and in doing so, you authorise the payment of such invoices using those details, you acknowledge and agree that ABC simply inputs the details into its practice and patient management software and that it is not responsible or liable for the storage, processing or transmitting of such details and you accept the Payment Processing Terms of ABC’s practice and patient management software which are available to view at https://halaxy.com/article/terms;
- That the services that ABC provides and your access to and use of the Facility involve a degree of risk, including physical and non-physical harm to yourself, and that you have voluntarily chosen to participate in the services that ABC provides and access and use the Facility, accepting that the materialisation of such risks may cause personal injury, death or property damage;
- That exercise or physical activity is physically demanding and may pose a risk to your health and you accept such risk;
- That you forever release and discharge ABC (and all of its contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns) and the Facility from any and all claims, actions, suits, demands, damages, interest and costs arising out of or as a consequence of any services provided by ABC or your access to and use of the Facility (Claims) for any loss, damage or injury to person (including yourself) or property whether caused by negligence, wilful act or omission, accident, another person or however otherwise caused; and
- That you forever indemnify ABC (and all of its contractors, employees, directors, officers, affiliates, subsidiaries, related parties, agents, successors and assigns) and the Facility against all Claims for any loss, damage or injury to person (including yourself) or property whether caused by negligence, wilful act or omission, accident, another person or however otherwise caused.