Pre Screening Medical Questionnaire

Please may parent / guardians complete this form on behalf of children under 18 years.

Question Title

* 1. Contact Details

Name *

Address *

Address 2

City/Town

State/Province

ZIP/Postal Code *

Country

Email Address *

Phone Number *

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* 2. What is your age?

0 to 4 years

5 to 7 years

8 to 11 years

12 to 15 years

16 to 17 years

18 to 24 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 to 74 years

75 or older

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* 3. Emergency Contact Details

Name

Phone Number

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* 4. Please state which activity session you're attending?

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* 5. Have you ever been told that you have a heart condition?

Yes

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* 6. Have you ever had a stroke?

Yes

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* 7. Do you ever have unexplained pains in your chest at rest or during physical exercise?

Yes

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* 8. Have you felt faint or fainted or suffer from spells of dizziness?

Yes

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* 9. Do you have asthma that requires medication?

Yes

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* 10. Do you have type I or II diabetes?

Yes

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* 11. Do you experience any major muscle or joint conditions that may limit you or be aggravated by physical activity

Yes

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* 12. Do you have high blood pressure over 140/90 or low blood pressure below 100/80?

Yes

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* 13. Do you have any medical conditions that may be made worse by participating in physical activity?

Yes

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* 14. Have you been told that you have high cholesterol?

Yes

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* 15. Have you been told that you have high blood sugar?

Yes

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* 16. Have you spent time in hospital for any medical condition/illness/injury/operation during the last 12 months?

Yes

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* 17. Are you currently on any medication?

Yes, please statement medication and for what condition?

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* 18. Are you pregnant?

N/A

Yes (Please specify how many weeks? Any related conditions?)

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* 19. Have you given birth in the last 12 months?

Yes

N/A

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* 20. Please state any other medical conditions which haven't been included above and maybe relevant to you taking part in physical activity?

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* 21. Please state if you have any allergies, disabilities or additional needs?

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* 22. Disclaimer:
If you have answered no to all of the above questions and you are confident that you have no other concerns with your health then you may proceed to participate in physical activity. If you have answered yes to any of the questions above or are unsure, please seek advice from your GP or allied health professional before commencing physical activity.

I believe to the best of my knowledge that all of the information I have provided on this form is accurate. In the case that my medical condition changes I will inform my instructor and fill out a new exercise pre screening questionnaire.

Please confirm that you have read, understand and agree with the above statements.

Yes

‘PRIVACY NOTICE - Your details are required in order to provide a Community Service Booking System Database, to take bookings for various community health & wellbeing activities & Museum, Heritage & Culture and record participant’s' details. The information that you have provided will be securely held by the Council and will only be accessed by authorised persons with the appropriate access controls. The Council will only use the information that you have provided for the purpose above and will not use it for any other purpose, unless you have given your consent, or this is otherwise required or permitted by law. For more information visit www.eppingforestdc.gov.uk/index.php/help/privacy’

Pre Screening Medical Questionnaire

Question Title

* 1. Contact Details

Question Title

* 2. What is your age?

Question Title

* 3. Emergency Contact Details

Question Title

* 4. Please state which activity session you're attending?

Question Title

* 5. Have you ever been told that you have a heart condition?

Question Title

* 6. Have you ever had a stroke?

Question Title

* 7. Do you ever have unexplained pains in your chest at rest or during physical exercise?

Question Title

* 8. Have you felt faint or fainted or suffer from spells of dizziness?

Question Title

* 9. Do you have asthma that requires medication?

Question Title

* 10. Do you have type I or II diabetes?

Question Title

* 11. Do you experience any major muscle or joint conditions that may limit you or be aggravated by physical activity

Question Title

* 12. Do you have high blood pressure over 140/90 or low blood pressure below 100/80?

Question Title

* 13. Do you have any medical conditions that may be made worse by participating in physical activity?

Question Title

* 14. Have you been told that you have high cholesterol?

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* 15. Have you been told that you have high blood sugar?

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* 16. Have you spent time in hospital for any medical condition/illness/injury/operation during the last 12 months?

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* 17. Are you currently on any medication?

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* 18. Are you pregnant?

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* 19. Have you given birth in the last 12 months?

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* 20. Please state any other medical conditions which haven't been included above and maybe relevant to you taking part in physical activity?

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* 21. Please state if you have any allergies, disabilities or additional needs?

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* 23. If you are a parent / guardian and have completed this form on behalf of a child under 18 years. Please write your name in the box below.