Adult Pre-Exercise Screening System

Email *

Consultation Date *

Full Name *

Date of Birth *

Address

City

State/Province

Zip/Postal

Country

Gender *

Female

Male

Prefer not to say

OtherOther

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

It is strongly recommended that you consult with your physician before beginning any exercise program.

You should be in good physical condition and be able to participate in the exercise.

Matt Shorrock trading as Eye of the Tiger Coaching is not a licensed medical care provider and represents that it has no expertise in diagnosing, examining, or treating medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition.

You should understand that when participating in any exercise or exercise program, there is the possibility of physical injury.

If you engage in this exercise or exercise program, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge Matt Shorrock trading as Eye of the Tiger Coaching from any and all claims or causes of action, known or unknown, arising out of any perceived negligence.

I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct. *