CHEN TAI CHI ACADEMY- EXERCISE SCREENING SYSTEM (APSS)
AIM: 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 and Tai Chi. 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. Please complete the questions below. Should you have any questions about the screening form please contact your exercise professional for clarification.

regards,
Sien
Chen Tai Chi Academy
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Email *
Mobile Phone *
Full Name *
Date of Birth *
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Gender *
Where did you hear about our Chen Tai Chi Academy? *
1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
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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 from an appropriate allied health professional or medical practitioner/doctor prior to undertaking Tai Chi Class.
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