Fillable STAGE 1 (COMPULSORY) ADULT PRE-EXERCISE SCREENING TOOL (Australian Correspondence Schools)

Fill Online, Printable, Fillable, Blank STAGE 1 (COMPULSORY) ADULT PRE-EXERCISE SCREENING TOOL (Australian Correspondence Schools) Form

Use Fill to complete blank online AUSTRALIAN CORRESPONDENCE SCHOOLS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STAGE 1 (COMPULSORY) ADULT PRE-EXERCISE SCREENING TOOL (Australian Correspondence Schools)

On average this form takes 16 minutes to complete

The STAGE 1 (COMPULSORY) ADULT PRE-EXERCISE SCREENING TOOL (Australian Correspondence Schools) form is 4 pages long and contains:

  • 1 signature
  • 27 check-boxes
  • 47 other fields

Country of origin: AUSTRALIA
File type: PDF

Australia forms for Australian Correspondence Schools

BROWSE AUSTRALIAN CORRESPONDENCE SCHOOLS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Copyright CHFI IP Holdings PTY LTD 2021 1
ADULT PRE-EXERCISE SCREENING TOOL
AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk
of an adverse event during physical activity/exercise. This stage is self administered and self evaluated.
ADULT PRE-EXERCISE SCREENING TOOL
This screening tool does not provide advice on a particular matter, nor does it substitute for advice from an
appropriately qualified medical professional. 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 and Sports Science Australia,
Fitness Australia or Sports Medicine Australia for any loss, damage or injury that may arise from any person acting on any statement or
information contained in this tool.
Name:
Date of Birth: Male: Female: Date:
STAGE 1 (COMPULSORY)
1. Has your doctor ever told you that you have a heart condition
or have you 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
attention 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 Yes No
in physical activity/exercise?
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 7 questions, please seek
guidance from your GP or appropriate allied health professional prior
to undertaking physical activity/exercise
IF YOU ANSWERED ‘NO’ to all of the 7 questions, and you have no
other concerns about your health, you may proceed to undertake
light-moderate intensity physical activity/exercise
I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
Signature: Date:
Please Select Yes or No
click to sign
signature
click to edit
Copyright CHFI IP Holdings PTY LTD 2021 2
ADULT PRE-EXERCISE SCREENING TOOL
EXERCISE INTENSITY GUIDELINES
INTENSITY
CATEGORY
SEDENTARY
< 40%
HRmax
40 to <55%
HRmax
55 to <70%
HRmax
70 to <90%
HRmax
≥ 90%
HRmax
Very, very light
RPE# < 1
Very light to light
RPE# 1-2
Moderate to
somewhat hard
RPE# 3-4
Hard
RPE# 5-6
Very hard
RPE# ≥ 7
• Activities that usually
involve sitting or lying and
that have little
additionalmovement and
a low energy requirement
• An aerobic activity that does
not cause a noticeable
change in breathing rate
• An intensity that can be
sustained for at least
60 minutes
• An aerobic activity that is
able to be conducted whilst
maintaining a conversation
uninterrupted
• An intensity that may last
between 30 and 60 minut
• An aerobic activity in which
a conversation generally
cannot be maintained
uninterrupted
• An intensity that may last
up to about 30 minutes
• An intensity that generally
cannot be sustained for
longer than about
10 minutes
LIGHT
MODERATE
VIGOROUS
HIGH
HEART RATE
MEASURES
PERCEIVED EXERTION
MEASURES
DESCRIPTIVE
MEASURES
# = Borg’s Rating of Perceived Exertion (RPE) scale, category scale 0-10
Copyright CHFI IP Holdings PTY LTD 2021 3
ADULT PRE-EXERCISE SCREENING TOOL
Name:
Date of Birth: Male: Female: Date:
AIM: To identify those individuals with risk factors or other conditions to assist with appropriate exercise prescription.
This stage is to be administered by a qualified exercise professional.
ADULT PRE-EXERCISE SCREENING TOOL
STAGE 2 (OPTIONAL)
1. Age
Gender
≥ 45yrs Males or ≥ 55yrs Females
+1 risk factor
If male < 55yrs = +1 risk factor
If female < 65yrs = +1 risk factor
Maximum of 1 risk factor for this question
If yes, (smoke regularly or
given up within the past 6 months) = +1 risk
factor
If physical activity level
< 150 min/ week = +1 risk factor
If physical activity level
≥ 150 min/ week = -1 risk factor
(vigorous physical activity/ exercise weighted
x 2)
BMI = ________________
BMI ≥ 30 kg/m2 = +1 risk factor
If yes, = +1 risk factor
If yes, = +1 risk factor
If yes, = +1 risk factor
RISK FACTORS
2. Family history of heart disease
(eg: stroke, heart attack)
Relative: Age: Relative: Age:
Father Mother
Brother Sister
Son Daughter
3. Do you smoke cigarettes on a daily or weekly basis
or have you quit smoking in the last 6 months?
Yes/No
If currently smoking, how many per
day or week?
4. Describe your current physical activity/exercise
levels:
Sedentary Light Moderate Vigorous
Frequency
(sessions per week)
Duration
(minutes per week)
5. Please state your height (cm)
weight (kg)
6. Have you been told that you have high blood
pressure? Yes/No
7. Have you been told that you have high cholesterol?
Yes/No
8. Have you been told that you have high blood
sugar? Yes/No
Note: Refer over page for risk stratification. STAGE 2 Total Risk Factors =
Female
0
Copyright CHFI IP Holdings PTY LTD 2021 4
ADULT PRE-EXERCISE SCREENING TOOL
9. Have you spent time in hospital (including day
admission) for any medical condition/illness/injury
during the last 12 months? Yes/No
10. Are you currently taking a prescribed
medication(s) for any medical conditions(s)?
Yes/No
11. Are you pregnant or have you given birth within
the last 12 months? Yes No
12. Do you have any muscle, bone or joint pain or
soreness that is made worse by particular types of
activity? Yes/No
1. BMI (kg/m2)
2. Waist girth (cm)
3. Resting BP (mmHg)
4. Fasting lipid profile*
Total cholesterol
HDL
Triglycerides
LDL
5. Fasting blood glucose*
BMI ≥ 30 kg/m2 = +1 risk factor
Waist > 94 cm for men and
> 80 cm for women = +1 risk factor
SBP ≥140 mmHg or DBP ≥90 mmHg
= +1 risk factor
Total cholesterol ≥ 5.20 mmol/L = +1 risk factor
HDL cholesterol >1.55 mmol/L = -1 risk factor
HDL cholesterol < 1.00 mmol/L = +1 risk factor
Triglycerides ≥ 1.70 mmol/L = +1 risk factor
LDL cholesterol ≥ 3.40 mmol/L = +1 risk factor
Fasting glucose ≥ 5.50 mmol = +1 risk factor
If yes, provide details
If yes, what is the medical condition(s)?
If yes, provide details. I am _____________ months
pregnant or postnatal (circle).
If yes, provide details
STAGE 3 (OPTIONAL)
RISK STRATIFICATION
AIM: To obtain pre-exercise baseline measurements of other recognised cardiovascular and metabolic risk factors.
This stage is to be administered by a qualified exercise professional. (Measures 1, 2 & 3 – minimum qualification,
Certificate III in Fitness; Measures 4 and 5 minimum level, Exercise Physiologist*).
Total stage 2
or
Total stage 3
Plus stage 2 (Q1 - Q4)
≥ 2 RISK FACTORS – MODERATE RISK CLIENTS
Individuals at moderate risk may participate in aerobic physical activity/exercise at a
light or moderate intensity (Refer to the exercise intensity table on page 2)
< 2 RISK FACTORS – LOW RISK CLIENTS
Individuals at low risk may participate in aerobic physical activity/exercise up to a
vigorous or high intensity (Refer to the exercise intensity table on page 2)
RESULTS
STAGE 3 Total Risk Factors =
Note: If stage 3 is completed, identified risk factors from stage 2 (Q1-4) and stage 3 should be combined to indicate risk. If there are extreme or multiple risk factors, the exercise professional
should use professional judgement to decide whether further medical advice is required.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STAGE 1 (COMPULSORY) ADULT PRE-EXERCISE SCREENING TOOL (Australian Correspondence Schools)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document