midlife Reset Adult Pre-Exercise Screening Name* First Last Today's Date* DD slash MM slash YYYY Phone*Email* DOB* DD slash MM slash YYYY Best Time of Day to Call* Gender*FemaleMale1. Has your doctor ever told you that you have a heart condition or have ever suffered a stroke?* Yes No 2. Do you ever experience unexplained pains in your chest at rest or during physical activity / exercise?* Yes No 3. Do you ever feel faint or have spells of dizziness during physical activity / exercise that causes you to lose balance?* Yes No 4. Have you had an asthma attack requiring immediate medical attentions at any time over the last 12 months?* Yes No 5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?* Yes No 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physicl activity/exercise?* Yes No 7. Do you have any other medical condition/s that may make it dangerous for you to participate in physical activity/exercise?* Yes No IF YOU ANSWERED YES to any of the above 7 questions please list details below and seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise.Physical activityDescribe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensitiesLight Activity*Sessions + Total Duration - ( - An aerobic activity that does not cause a noticeable change in breathing rate - An intensity that can be sustained for at least 60 minutes) Moderate Activity*Sessions + Total Duration - ( -An aerobic activity that is able to be conducted whilst maintaining a conversation uninterrupted - An intensity that may last between 30 and 60 minutes) Vigorous / HighSessions + Total Duration. - ( -An aerobic activity in which a conversation generally cannot be maintained uninterrupted - An intensity that may last up to 30 minutes OR - An aerobic activity in which it is difficult to talk at all - An intensity that generally cannot be sustained for longer than about 10 minutes) Please list any existing injuries and briefly outline your current fitness activies below.I hereby understand that by using Real Girl Sweat services I am participating in sporting/recreational activity which involves obvious risk. I also note that Civil Liability Act 2002 NSW states that no duty of care exists when reasonable warning of risk is given. I acknowledge that I am participating in activities of risk and I acknowledge this waiver as my understanding of the obvious risk.* Yes I agree to the above.
