Health and Wellbeing Exercise Pre-Screening Consultation

– Step 1 of 5

Personal & Contact Information

Name *

First

Last

Date of Birth *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Mobile / Home Phone *

Email *

Name *

First

Last

Emergency Mobile / Home Phone *

Emergency Relationship *

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

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

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

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

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

Do you have any other conditions that may require special consideration for to exercise? *

Please elaborate *

IF YOU HAVE ANSWERED NO to any of the questions above and you are confident you have no other concerns with your health then you may proceed to participate in physical activity/exercise. IF YOU ANSWERED YES to any of the above questions or are unsure, you may need to seek medical clearance from your GP or allied professional before commencing physical activity/exercise.

I accept

I believe to the best of my knowledge that all the information in this pre-screening questionnaire I have provided is accurate. In the case that my medical condition changes over the course of my training I will inform my trainer and fill out a new exercise pre- screening questionnaire.

Do you have a family history of heart disease or stroke? *

If yes, relationship and age at event? *

Have you had surgery which may be affected by or limit your exercise program? *

Can you please elaborate? *

Have you spent time in hospital for any condition, illness or injury in the last 12 months? *

What was the reason and for how long were you hospitalised? *

Do you have any major illnesses or injuries that may be affected by beginning an exercise program? *

Can you list them? *

Are you currently on any prescription medication? *

Can you list them? *

Are you pregnant or have you given birth in the past 12 months? *

Are you aware of what constitutes ‘healthy eating’? *

Are you suffering symptoms associated with Menopause? *

Can you list your symptoms? *

How much water do you consume each day? *

None
250ml – 1Lt
1Lt – 2Lt

Do you smoke? *

How long have you smoked and approximately how many per day? *

Have you quit smoking in the past 6-months? *

Do you drink alcohol? *

Would you say you drink alcohol socially or regularly? *

Socially
Regularly

How many days per week would you approximately drink alcohol? *

Would you consider yourself a Light, Moderate or Heavy Drinker? *

Light
Moderate
Heavy

What is your current Occupation? *

In your current occupation would you consider your exertion levels Sedentary, Light, Moderate or Physical? *

Sedentary
Light
Moderate
Physical

Are you currently participating in regular physical activity/exercise? *

How long have you been particpating? *

FYI – 150 mins is the AUS active recommended amount of light to moderate intensity exercise per week. If your total is less than the recommended amount, please increase your volume and intensity slowly and carefully.

Check the boxes that align with your Health & Fitness Goals *

Reduce Body Fat
Increase Cardiovascular Fitness
Build Muscle & Strength
Health Weight Gain
Specific Sport Training
Mental Wellbeing
Injury Rehabilitation
General Health

How many sessions per week do you hope to maintain? and what duration per session are you expecting? *

I agree

It is important that you work at a safe and achievable level when you first begin any fitness program. Please follow your trainer’s advice and learn the correct technique for each of your exercises before increasing intensity. If you feel discomfort or unusual pain when performing any exercise omit that exercise and seek advice from a trainer or medical professional.

I recognise the instructor/trainer is not able to provide me with medical advice and that the information given today is used as a guide to the limitations and best interests of my exercise abilities. I have answered the above questionnaire as true and to the best of my knowledge that I’m able to at present.

This Privacy Policy outlines how Barooga Aquatic and Recreation Centre manages personal information and its commitment to quality services. They adhere to the Australian Privacy Principles (APPs) under the Privacy Act 1988 (Cth) to govern the collection, use, disclosure, storage, security, and disposal of personal information.

Personal information collected includes names, addresses, email addresses, and phone numbers from various sources, including correspondence, phone calls, emails, the website, media, and third parties. It is used primarily for providing services, client information, and marketing. By agreeing to these terms, you give permission for Barooga Aquatic and Recreation Centre to include you in marketing communications.

Sensitive information (e.g., racial or ethnic origin, health information) is used only for the primary purpose it was collected for, related secondary purposes, with consent, or as required by law.

Personal information may be disclosed with consent or as required by law. Security measures are in place to protect personal information from misuse, loss, or unauthorized access.

Individuals can access, update, or correct their personal information, subject to exceptions. Barooga Aquatic and Recreation Centre may charge an administrative fee for providing copies of personal information.

Maintaining accurate and up-to-date personal information is important, and individuals are encouraged to notify the center of any inaccuracies.

By agreeing to these terms, you give permission for photos obtained during the 8-week program to be used in marketing collateral.

The Privacy Policy may change periodically and is available in full at https://baroogaarc.com.au/privacy-policy/

For privacy-related inquiries or complaints, contact the centre at the provided address, email, or phone number.

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Health and Wellbeing Exercise Pre-Screening Consultation

Personal & Contact Information

Barooga Aquatic and Recreation Centre

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