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  • Pre-Exercise Screening Tool and Personal Information

  • This screening tool has been modified from the ESSA, Fitness Australia and Sports Medicine Australia exercise pre-screening tool. Fitness Keeper does not take any credit for this screening tool. The tool does not provide advice from any qualified professionals. No warranty of safety should result from its use. The screening tool does not guarantee against injury or death. No responsibility or liability whatsoever can be accepted by Exercise and Sports Science Australia, Fitness Australia, Sports Medicine Australia, or Fitness Keeper for any loss, damage or injury that may arise from any person acting on any statement or information contained in this tool.
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  • What is your Gender?*

  • Emergency Contacts

    Please provide two.
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  • Pre-Exercise Screening Stage 1 (Compulsory)

    Aim: To identify any individuals with a known disease, or signs or symptoms of disease, who may be at higher risk of an adverse event during physical activity/exercise. This stage is selfadministered and self-evaluated.
  • Q1: Has your doctor ever told you that you suffer from a heart condition (e.g. coronary heart disease, arrhythmias, etc.) or have you ever suffered from a stroke?*
  • Q2: Do you ever suffer from unexplained chest pains or discomfort at rest or during exercise/activity?*
  • Q3: Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*
  • Q4: Have you had an asthma attack which required immediate medical attention at any time in the past 1 year?*
  • Q5a: Do you suffer from Diabetes*
  • Q5b: If you answered "yes" to diabetes, have you had any trouble controlling your blood glucose (blood sugar) levels within the past 3 months?*
  • Q6: Do you have any other conditions that you are aware of that may require special consideration for you to engage in exercise (e.g. cancer, obesity, kidney disease, etc.)?*

  • If you answered YES to any of the questions above...

    Please seek guidance from an appropriate medical practitioner prior to undertaking exercise. Fitness Keeper can provide you with a relevant form, which you can take with you to your doctor for clearance to engage in our exercise programs.

  • If you answered NO to all questions...

    Please continue to complete the form.
  • Do you have any diagnosed muscle, joint, ligament, tendon or bone problems that limit you or are exacerbated by physical activity or exercise?*

  • Do you have poor pelvic floor control/trouble controlling your bladder during exercise?
  • Do you smoke cigarettes on a daily or weekly basis, or have you quit smoking in the last 6 months
  • Have you ever been told you have high blood pressure?
  • Have you ever been told you have high cholesterol or high blood lipids?
  • Have you ever been told you have high blood sugar (glucose)?
  • Are you pregnant or post natal?
  • Have you been hospitalized (including day admission) for any medical condition/ illness/ injury during the last year?
  • Due to government Covid-19 restrictions, we can only accept participants who have been double vaccinated. Please confirm your vaccination status.*
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  • Consent Form

  • I confirm with my signature at the end of this document, my involvement as a participant in personal training or exercise physiology activities, fitness activities, and exercise sessions to be provided by Fitness Keeper.

    I confirm that I am participating pursuant to my desire to do so and of my own free will. In being such a participant, I acknowledge, understand, and accept that:

    1.       I understand that my participation in the program can enhance both musculoskeletal and cardiorespiratory systems and may improve my ability to perform daily activities.

    2.       The program will include activities of exercise at various intensities.

    3.       There are inherent risks in participating in the program. For example, the program could result in injuries, soreness, illness, exhaustion, pain and discomfort, which may have differing levels of temporary or permanent consequences to my overall health. I may also experience some form of discomfort in the form of breathlessness or muscular fatigue during exercise.

    4.       That, if during the undertaking of the program, I at any stage have apparent adverse effects, including, for example, light headedness, feeling faint, experiences of pain or discomfort, I will immediately cease the activity that I am undertaking and inform the trainer.

    5.       I give my trainer, exercise scientist, or exercise physiologist/Fitness Keeper permission to seek emergency medical services for me, should Fitness Keeper believe the same to be necessary in the event of me becoming ill or injured, and I understand that I will be responsible for any expenses thereby incurred.

    6.       Attached to this form is a form completed by me setting out my personal details, medical and health history, which I have completed in accordance with its requirements.

    7.       It is my responsibility for my initial decision to participate and for my continued participation in the program. I understand I may withdraw at any time.

    8.       I agree to release, hold harmless and forever discharge the trainer, exercise scientist, or exercise physiologist/ Fitness Keeper for any liability for loss, damage, injury, or expense that I may suffer now or in the future as a result of my participation in the program.

    9.       I have read and accepted the Terms and Conditions (including the cancellation policy).

    10.   I understand that my information may be stored electronically with password protected safeguards. Any paper data (such as consent forms and documents) will be stored in a locked filing cabinet.

     

    For those under 18 years of age, a parent or legal guardian will need to acknowledge the above on their behalf.

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