Pre-Exercise Screening Questionnaire This is to be completed in preparation for physical activity. It is important that you disclose ALL of your existing medical conditions so that we/I may determine whether to seek further medical advice before commencing your training. This questionnaire does not provide medical advice in any form and does not substitute advice from appropriately qualified professionals.PrefixMr.Mrs.Ms.Mx.MissDr.Prof.First Name *Last Name *Street Address *State/ProvinceZIP / Postal CodePhone *Date of birth *Age *Email Address *Emergency Contact NameEmergency Contact PhoneDo you currently have any of the following conditions that may affect your training? (Please tick all that apply)Have you ever been told that you have a heart condition?YesNoHave you ever had a stroke?YesNoDo you ever have unexplained pains in your chest at rest or during physical exercise?YesNoDo you consistently feel faint or suffer from spells of dizziness?YesNoDo you suffer from asthma and require medication?YesNoDo you carry your medication with you?YesNoDo you suffer from type I or II diabetes?YesNoDo you suffer from any major muscle or joint conditions that may limit you or be aggravated by physical activity?YesNoDo you suffer from any medical conditions that may be made worse by participating in physical activity?YesNoDo you suffer from high blood pressure over 140/90 or low blood pressure below 100/80?YesNoDo you have a family history of heart disease? (stroke, heart attack)?YesNoHave you been told that you have high cholesterol?YesNoHave you been told that you have high blood sugar?YesNoHave you spent time in hospital for any medical condition/illness/injury during the last 12 months?YesNoIf you answered 'yes' to any of the questions above, please elaborate on how this has affected your recent training and/or may be relevant to your training session(s).Are you currently pregnant?YesNoAre there any issues relating to current or past pregnancies that may impact your training?YesNoUnsureIf you feel comfortable to do so, please describe any pregnancyrelated issues and their possible impacts on your trainingIf 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 a Strength Coaching Australia session. If you have answered 'yes' to any of the questions above or are unsure, and you have never participated in weights or barbell training before, please seek a referral from your GP or allied health professional before commencing physical activity. If you answered 'yes' to any of the questions above but are already regularly engaging in the type of physical activity you will be performing in your session, then please discuss the details with Strength Coaching Australia prior to commencing your session.Do you smoke?YesNoHow many cigarettes per day/week?Are you currently on any medication?YesNoWhat is it and for what condition?Consent *I believe to the best of my knowledge that all of the information I have provided in this questionnaire is accurate. In the case that my medical condition changes over the course of my training I will inform my trainer and fill out a new exercise pre-screening questionnaire.Training goals and expectationsWhat do you want to get out of your initial Strength Coaching Australia session?Describe your longer-term training/performance goals and how professional coaching can assist with these.If you want to work on a particular movement or movements, please complete the relevant sections of the following table (or describe in the space below):SquatSelect appropriateLow barHigh barFrontAll time PRRecent PRRecent rep PRMost recent training (RPE & Date)e.g. 5 reps @ 60kg, 3 sets (RPE 8 )BenchAll time PRCheck appropriateWith pauseTouch & goRecent PRCheck appropriateWith pauseTouch & goRecent rep PRCheck appropriateWith pauseTouch & goMost recent training (RPE & Date)Check appropriateWith pauseTouch & goDeadliftSelect appropriateConventionalSumoAll time PRRecent PRRecent rep PRMost recent training (RPE & Date)e.g. 5 reps @ 60kg, 3 sets (RPE 8 )Overhead PressSelect appropriateStrictPushJerkAll time PRRecent PRRecent rep PRMost recent training (RPE & Date)e.g. 5 reps @ 60kg, 3 sets (RPE 8 )Current body weight if relevant, an estimate is fine:Please provide your training program if you wish to have it reviewed prior to the session and if practical, send short lifting clips for review.Finally, if there any other information that could assist in getting the most out of your coaching session, then please outline below:SubmitSave as Draft
