Exercise 4 Health - Self Referral

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The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor or a qualified exercise professional before becoming more physically active.

If selecting Yes on any of these questions you may need to consult your doctor before participating in physical activity.

Email *

Name

Emergency Contact Name and No.

Current Long Term Health Condition(s) *

What symptoms do you experience when exercising?

Do you feel pain in your chest when you do physical activity?

Yes

Clear selection

In the past month, have you had a chest pain when you were not doing physical activity?

Yes

Clear selection

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

Clear selection

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?

Yes

Clear selection

Is your doctor currently prescribing medication for your blood pressure or a heart condition?

Yes

Clear selection

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer no if you had a problem in the past, but it does not limit your current ability to be physically active.

Yes

Clear selection

Has your doctor ever said that you should only do medically supervised physical activity?

Yes

Clear selection

In the last 14 days have you knowingly had Covid-19 or symptoms of Covid-19 such as loss of taste, fever, cough?

Yes

Clear selection

"I have read, understood and completed the questionnaire. By selecting 'Agree' it will act as my signature on this questionnaire confirming I am fit to participate in physical activity." *

Full Name and Date *

Send me a copy of my responses.

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