Member Medical Screening Form
Name
Date
Gender
Male
Female
Date Of Birth
1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?
Yes
No
2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?
Yes
No
3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?
Yes
No
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?
Yes
No
5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?
Yes
No
6. Do you have any other conditions that may require special consideration for you to exercise?
Yes
No
IF YOU ANSWERED ‘YES’ to any of the 6 questions, please seek guidance from an appropriate allied health professional or medical practitioner prior to undertaking exercise. Please upload any information from your doctor below.
I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.
Complete