Best Practice Living

• Before starting any exercise program there are some very important things that you need to know about exercising and we as responsible trainers need to know about you.

  Privacy Statement

  The information you give on this pre activity questionnaire is collected for the primary purpose of advising you on the appropriateness of a doctor’s clearance before exercising. Other purposes of collection include the creation of a record on Best Practice Personal Training database, attending to administrative matters and corresponding with you. No personal information collected from you will be passed on to any other organisation without your consent.

  Why is pre-exercise screening important?

  Best Practice Personal Training has a duty of care to ascertain that it is safe for you to perform regular exercise. Although there is no specific law that requires us to conduct pre-exercise screening or that describes this process, we see the PAQ process as one that satisfies both parties’ need to know of your current capacity to participate in an exercise program. Professional associations for exercise specialists, such as the Australian Association for Exercise and Sports Science (AAESS), acknowledge that pre-exercise screening is an important part of the duties of an exercise specialist. We therefore adopt this as part of our procedures.

  Personal Details

  1. Name(required)
  2. Address(required)
  3. Postcode(required)
  4. Email(valid email required)
  5. Phone(required)
  6. D.O.B(required)
  7. Profession
  8. Health Practitioners you use (e.g. Physiotherapist)

  Medical Conditions

  1. Have you ever been diagnosed with a cardiovascular disease, including cardiac, peripheral vascular, or cerebral vascular disease
  2. Yes No
  3. Have you ever been diagnosed with a pulmonary disease, including chronic obstructive pulmonary, asthma, interstitial lung, or cystic fibrosis?
  4. Yes No
  5. Have you ever been diagnosed with metabolic disease including diabetes, thyroid disorder, renal or liver disease?
  6. Yes No
  7. Are you, or do you have reason to believe, you may be pregnant?
  8. Yes No
  9. Is there any other physical reason that prevents you from participating in an exercise program? (e.g., cancer,osteoporosis, severe arthritis, mental illness etc.)
  10. Yes No

  Medication

  1. Please list any medication you are currently taking.

  Signs and Symptoms

  1. Do you often have pains in your heart, chest, or surrounding areas, especially during exercise?
  2. Yes No
  3. Do you often feel faint or have spells of severe dizziness during exercise?
  4. Yes No
  5. Do you experience unusual fatigue or shortness of breath at rest or with mild exertion?
  6. Yes No
  7. Have you had an attack of shortness of breath that came on after you stopped exercising?
  8. Yes No
  9. Have you been awakened at night by an attack of shortness of breath?
  10. Yes No
  11. Do you experience swelling or accumulation of fluid in or around your ankles?
  12. Yes No
  13. Do you often get the feeling that your heart is beating abnormally, racing, or skipping beats, either at rest or during exercise?
  14. Yes No
  15. Do you regularly get pains in your calves and lower legs during exercise which are not due to soreness, stiffness or fatigue?
  16. Yes No
  17. Has your doctor ever told you that you have a heart murmur?
  18. Yes No

  Cardiac Risk Factors

  1. Current cigarette smoker or those who have quit within the last 6 months
  2. Yes No
  3. Has your doctor ever told you that you have high blood pressure, i.e. systolic blood pressure >140 or diastolic >90 confirmed by measurements on two separate occasions or on anti-hypertensive medication
  4. Yes No
  5. Has your father, brother, or son suffered heart attack, stroke or sudden death before the age of 55 or your mother or other first degree female relative before 65?
  6. Yes No I don't know
  7. Is your total serum cholesterol > 5.2 or HDL <.9 or are you on lipid lowering medication. If known is your LDL > 3.4?
  8. Yes No I don't know
  9. Is your fasting glucose, confirmed by measurements on at least 2 separate occasions > 6.1
  10. Yes No I don't know
  11. Is your Body Mass Index >30 (weight in kg divided by height in metres squared or is your waist > 100 cm
  12. Yes No I don't know
  13. Do you participate in regular large muscle group activity (e.g running, swimming, cycling) 3 or more times per week for at least 20 mins at moderate intensity (slightly out of breath)
  14. Yes No

  Exercise Intentions

  1. Does your job involve sitting for a large part of the day?
  2. Yes No
  3. What are your current activity patterns...
  4. a) Frequency (Number of exercise sessions per week)
  5. b) Intensity of the sessions (Light, Moderate, Vigorous)
  6. c) For how long have you been following this exercise pattern?
  7. d) What types of exercises/activities do you do?
  8. e) What is the average duration of these exercise sessions?
  9. Do you want to exercise at a moderate intensity (e.g., brisk walking) or at a vigorous intensity (e.g., running)?
  10. Moderate Vigorous
  11. Tick activities that you would like to do as part of the exercise program
  12. Strength training
      Cycling
      Running
      Swimming
      Kick bike
      Boxing
      Circuit training
  13. List any operations, injuries (both current and previous) that you have had and or think may affect any exercises you expect to engage in as part of your program. E.g back or knee injuries

   

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