Foot & Ankle Blueprint: Medical Pre-Screening

Please answer the following questions to the best of your ability so we can ensure you are safe to exercise and participate in Exercise Physiology services provided by Resilience Rehab & Performance Pty Ltd.

What's Your Name?

First Name

Last Name

How Can We Best Contact You If Needed?

Mobile Number

When Were You Born?

Date of birth

Gender

Male

Female

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

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Do you have any diagnosed muscle, bone, tendon, ligament or joint problems that you have been told could be made worse by participating in exercise?

If yes, please list with as much detail as possible.

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How long have you been experiencing the problem/s?

Do you have a family history of heart disease?

Including but not limited to; high blood pressure, stroke, heart failure, heart attack?

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Please outline any past medical history.

Allergies or any other underlying/chronic conditions

Please outline any past medical history.

Have you ever had, or do you currently have any of the following?

If no, select "none of the below"

Health Check

None of the below

Immunosuppression

Bladder dysfunction

Cancer

Night pain

Recent physical trauma

Loss of sensation to the area around or between the penis, vagina, anus and/or inner surfaces of the thighs?

Lower body neurological deficit (numbness or inability to use limbs)

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

Yes

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

Yes

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

Yes

Do you have any other conditions that may require special consideration for you to exercise?

If yes or maybe, please outline in detail below

Do you have any other conditions that may require special consideration for you to exercise?

Yes

Maybe

Are you currently taking prescribed medication(s)?

If not, type no. If yes, please list with schedule and amounts.

Are you currently taking prescribed medication(s)?

Do you smoke cigarettes on a daily or weekly basis or have you quit smoking in the last 6 months?

Yes

Have you ever been told you have high blood pressure?

Have you been told you have high blood pressure?

Yes

Are you pregnant or have you given birth within the last 12 months?

Have you been told you have high blood pressure?

Yes

Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?

If not, type no. If yes, please list with as much detail as possible.

Have you spent time in hospital (including day admission) for any condition/illness/injury during the last 12 months?

Select the option which best represents your current physical activity/exercise levels in a typical week.

Describe your current physical activity/exercise levels in a typical week.

Little to none

Very light, but consistently

Moderate to hard, consistently

5-7 days per week, very hard

Consent

By ticking this box I acknowledge I answered the previous questions honestly and to the best of my ability.

I also acknowledge that I understand the risks associated with exercise (the benefits of physical activity far outweigh the possible associated risks in most individuals.

However, I recognise that, despite all precautions on the part of Resilience Rehab & Performance Pty Ltd, there are risks of injury or illness including but not limited to certain acute physiological changes and musculoskeletal injury: muscular strains, joint sprains, delayed muscle soreness, abnormal blood pressure, fainting, disturbances of heart rhythm, and in very rare instances heart attack and stroke.)

Finally, I agree if the health history, physical activity readiness questionnaire or evaluation indicates that I should see my physician before exercising, I will do so.

Consent

Yes

Signature

Please type your full name to acknowledge you have completed this form to the best of your ability.

Signature