Form 01 @ Rehability

Pre-Exercise Questionnaire

Personal Information

First Name:

Last Name:

Date of Birth:

00/00/1900

Address Line 1:

Address Line 2:

Suburb:

Post Code:

State:

Contact Phone:

Fax:

Email Address:

Doctor's Details

Doctor's Name:

Doctor's Phone:

Emergency Contact Information

Contact Person:

Contact Phone:

Medical History:

List ALL medications you are regularly taking and reasons for taking them:

Do you have/had or been told by a doctor that you are at risk of:

High Blood Pressure
High Cholesterol
Cardiovascular Disease
Lung Disorder

Do you have diabetes?:

Yes
No

If yes what type type?:

Type 1
Type 2

How long have you had diabetes?:

Have you ever had pain or pressure, either at rest or during exercise:

In the middle of, or the left side of the chest
In the neck or jaw region
In the left shoulder or down the left arm

Have you in the past 12 months, had an attack of shortness of breath that came on when you were not doing anything strenuous?:

Yes
No

Do you experience swelling or accumulation of fluid around the ankles?:

Yes
No

Do you regularly get pain in the calves and lower limbs during exercise not due to soreness or stiffness?:

Yes
No

Do you have a close relative who has had a stroke, heart attack or other cardiovascular disease?:

Yes
No

If yes what relation is this person:

At what age did he/she suffer this disease:

Did your relative die suddenly as a result of the disease?:

Yes
No

Have you ever smoked cigarettes?:

Yes
No

If yes, do you currently smoke?:

Yes
No

Yes, but stopped smoking:

Less than 5 years ago
More than 5 years ago

Have you ever experienced a brain or spinal injury that has required medical attention?:

Yes
No

Any Details:

Have you ever suffered any nervous system injury, such as lesion or damage to a nerve, numbness or pins and needles?:

Yes
No

Any Details:

Have you experienced any unusual muscular or joint pain in the past 12 months?:

Yes
No

Any Details:

Have you sustained a fracture or undergone joint replacement surgery which causes you on-going problem?:

Yes
No

Any Details:

Do you or your immediate family suffer from any chronic musculoskeletal problems such as osteoporosis and osteoarthritis?:

Yes
No

Who/where Details:

Do you have any condition that may require special consideration when exercising or that would prevent you from exercising? (eg cancer, liver/kidney/thyroid disease, HIV/AIDS, Parkinson's Disease, Multiple Sclerosis, Chronic Fatigue Syndrome etc):

Yes
No

Any Details:

Do you experience or have you ever experienced:

Epilepsy
Fainting
Convulsions
Seizures
Dizzy Spells

Have you undergone any surgery in the past 12 months?:

Yes
No

Any Details:

Are you or have you received treatment from an allied health professional in the last 6 months? (eg Chiro, Physio, Osteopath)

Yes
No

Any Details

Are you, or do you believe you could be pregnant?:

Yes
No

Did you experience menopause before the age of 45? :

Yes
No

Current Activity Patterns (please choose one from each column):

I have read, understood and answered this questionnaire honestly. I will notify the treating Exercise Physiologist if my health status changes or medical condition changes in relation to the above questions.

If at any stage I experience chest, leg/arm pain, shortness of breath or dizziness while exercising I will immediately notify the supervising Exercise Physiologist.

Please ensure all information is correct before clicking the submit button: