Prescreening Form | Real Lifestyle Solutions

First name

Last name

Phone

Birthday

Day

Month

Year

Emergency Contact Name & Relationship

Emergency Contact Phone

Did someone tell you about these classes? If yes, please let us know their full name so we can say thanks:

ADULT PRE-EXERCISE SCREENING SYSTEM (APSS)

This screening tool is part of the Adult Pre-Exercise Screening System (APSS) that also includes guidelines (see User Guide) on how to use the information collected and to address the aims of each stage. No warranty of safety should result from its use. The screening system in no way guarantees against injury or death. No responsibility or liability whatsoever can be accepted by Exercise & Sport Science Australia, Fitness Australia, Sports Medicine Australia or Exercise is Medicine for any loss, damage, or injury that may arise from any person acting on any statement or information contained in this system.

Stage 1

To identify individuals with known disease, and/or signs or symptoms of disease, who may be at a higher risk of an adverse event due to exercise. An adverse event refers to an unexpected event that occurs as a consequence of an exercise session, resulting in ill health, physical harm or death to an individual. This stage may be self-administered and self-evaluated by the client. Should you have any questions about the screening form please contact your exercise professional for clarification.

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

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

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

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

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

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

IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance and clearance letter from an appropriate allied health professional or medical practitioner prior to undertaking exercise.

IF YOU ANSWERED ‘NO’ to all of the 6 questions, please proceed to question 7 and calculate your typical weighted physical activity/exercise per week.

7. Describe your current physical activity/exercise levels in a typical week by stating the frequency (days per week) and duration (minutes) at the different intensities. Also note the intensity level: light/moderate/high

Total minutes per week = (minutes of light + moderate) + (2 x minutes of vigorous/high)

I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.

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Do you have any health or medical conditions that we should know about?

Medical clearance letter

Participant Declaration and Waiver

I acknowledge that participation in fitness classes and physical activity involves inherent risks, including the risk of injury. I confirm that the information provided in this form is accurate and complete to the best of my knowledge. I agree to inform the instructor of any changes to my health status that may affect my participation.

I understand that it is my responsibility to seek medical advice where appropriate and to provide medical clearance if requested. By participating in classes, I do so voluntarily and accept responsibility for my own health and wellbeing.

I release and hold harmless Real Lifestyle Solutions, its instructors, and representatives from liability for any injury, illness, loss, or damage arising from participation, except where caused by negligence.

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