[PC] One-Off Consult Pre-Screening

Pain Codex One-Off Consult: 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.


30 Questions

What Is Your Name?*

Enter Your Best Email and Phone*

Date of birth*


Describe the problem/s you are looking for help with?*

What are you having the most trouble with and how is it impacting you?

How long have you been experiencing the problem/s?*

Please list any current or previous muscle, bone, tendon, ligament or joint problems.*

As much detail as possible.

Please outline any past medical history.*

Allergies or any other underlying conditions

Do you currently have or have had any of the following before?*

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

Do you have a family history of heart disease?*

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

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

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

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

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

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

Are you currently taking prescribed medication(s)?*

If yes, please list with schedule and amounts.

Do you drink alcohol?*

If yes, please outline on average how many drinks per week.

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

Have you been told you have high blood pressure?*

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

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

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

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

Please describe your current training here in-depth.*

Current program including day splits/exercises, cardio, walking etc

Have you recently changed or increase your training/exercise load?*

If yes, please elaborate.

Please list all of the equipment you currently have access to.*

If full gym, just type that. If you train at home, please list everything you have.


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.


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