* = Required
GETTING STARTED First Name: *
Last Name: *
Date Of Birth:
Sex: MF
Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone: *
Email: *
Emergency Contact:
Emergency Contact Number:
How did you hear about us?
Have you ever fainted? YesNo
Why?
When?
What is your blood type?:
Are you currently pregnant? YesNo
Are you taking any medications? YesNo
Please specify:
Do you have any allergies? YesNo
Have you had any surgeries? YesNo
Do you have any past/present injuries? YesNo
MEDICAL HISTORY Do you have any past or present health issues or any issues that are in your family history? (Please check all that apply to you)
Cardiovascular Disease NoneArteriosclerosisAneurysmVaricose VeinsStrokeCholesterol
Heart Disease NoneHigh BloodLow Blood PressureHeart murmurAngina pectorisMyocardial InfarctionRheumatic feverCardiac ArrhythmiaTachycardia
Neurological Disorder NoneEpilepsyImpingemen Syn.SciaticaInsomia
Muscular-Skeletal Disorder NoneOsteoarthritisOsteoporosisRheumatoid arthritisTendonitis/BursitisWhiplashFibromyalgiaHerniated disc
Respiratory Disorder NoneAsthmaEmphysemaOther
Endorine Disorder NoneDiabetesHyperthyroidismHypothyroidism
Heart Disease NoneHerniaAnaemiaChronic fatigue syn.UlcersAllergiesTumour/cystSickle cellMigraines
If one or more of the above conditions relate to you, please provide a brief detail (e.g. surgery/doctor’s recommendation)
Do you have any pain in the following areas? (If yes, please mark the box that best describes the severity and location of pain that you feel)
Toes (Left) YESNOEXTREMEMODERATEMILD
Toes (Right) YESNOEXTREMEMODERATEMILD
Forefoot (Left) YESNOEXTREMEMODERATEMILD
Forefoot (Right) YESNOEXTREMEMODERATEMILD
Arch (Left) YESNOEXTREMEMODERATEMILD
Arch (Right) YESNOEXTREMEMODERATEMILD
Heel (Left) YESNOEXTREMEMODERATEMILD
Heel (Right) YESNOEXTREMEMODERATEMILD
Ankle (Left) YESNOEXTREMEMODERATEMILD
Ankle (Right) YESNOEXTREMEMODERATEMILD
Leg (Left) YESNOEXTREMEMODERATEMILD
Leg (Right) YESNOEXTREMEMODERATEMILD
Knee (Left) YESNOEXTREMEMODERATEMILD
Knee (Right) YESNOEXTREMEMODERATEMILD
Hip (Left) YESNOEXTREMEMODERATEMILD
Hip (Right) YESNOEXTREMEMODERATEMILD
Low YESNOEXTREMEMODERATEMILD
Back YESNOEXTREMEMODERATEMILD
Shoulders (Left) YESNOEXTREMEMODERATEMILD
Shoulders (Right) YESNOEXTREMEMODERATEMILD
Elbow (Left) YESNOEXTREMEMODERATEMILD
Elbow (Right) YESNOEXTREMEMODERATEMILD
Neck YESNOEXTREMEMODERATEMILD
Wrist (Left) YESNOEXTREMEMODERATEMILD
Wrist (Right) YESNOEXTREMEMODERATEMILD
Hand (Left) YESNOEXTREMEMODERATEMILD
Hand (Right) YESNOEXTREMEMODERATEMILD
Fingers (Left) YESNOEXTREMEMODERATEMILD
Fingers (Right) YESNOEXTREMEMODERATEMILD
LIFESTYLE HABITS/BEHAVIOUR
Occupation
Description of work performed
Hours worked per week
Number of days worked per week
Do you find your occupation stressful? YesNoSometimes
What do you do for stress relief?
Do you currently smoke? YesNo
Have you ever smoked? YesNo
If Yes, for how long?
Do you drink alcohol? YesNo
If Yes, how many drinks per week?
Do you drink coffee/tea? YesNo
If Yes, how many cups per week?
How is your sleeping pattern? GoodAveragePoor
How many hours do you sleep per night?
GENERAL HEALTH QUESTIONS
Please read the 7 questions below carefully and answer each one honestly:
1) Has your doctor ever said that you have a heart condition or high blood pressure? * YesNo
Heart ConditionHigh Blood PressureNo Answer
2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? * YesNo
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). * YesNo
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? * YesNo
PLEASE LIST CONDITION(S) HERE:
5) Are you currently taking prescribed medications for a chronic medical condition? * YesNo
PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active. * YesNo
7) Has your doctor ever said that you should only do medically supervised physical activity? * YesNo
If you answered NO to all of the questions above, you are cleared for physical activity. Please check the Participant Declaration box below
Start becoming much more physically active – start slowly and build up gradually.
Follow Global Physical Activity Guidelines for your age.
You may take part in a health and fitness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualified exercise professional.
If you answered YES to one or more of the questions above, complete the section below
Delay becoming more active if:
You have a temporary illness such as a cold or fever; it is best to wait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, and/or complete the ePARmed-X+ at www.eparmedx.com before becoming more physically active.
Your health changes - answer the questions on Pages 2 and 3 of this document and/or talk to your doctor or a qualified exercise professional before continuing with any physical activity program.
FOLLOW UP QUESTIONS
1. Do you have Arthritis, Osteoporosis, or Back Problems? * YesNo
1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)? YesNoNo Answer
1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months? YesNoNo Answer
2. Do you currently have Cancer of any kind? * YesNo
2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck? YesNoNo Answer
2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)? YesNoNo Answer
3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm * YesNo
3a. Do you have dificulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
3b. Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction) YesNoNo Answer
3c. Do you have chronic heart failure? YesNoNo Answer
3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months? YesNoNo Answer
4. Do you currently have High Blood Pressure? * YesNo
4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure) YesNoNo Answer
5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes? * YesNo
5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies? YesNoNo Answer
5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness. YesNoNo Answer
5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet? YesNoNo Answer
5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)? YesNoNo Answer
5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future? YesNoNo Answer
6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome? * YesNo
6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
6b. Do you have Down Syndrome AND back problems affecting nerves or muscles? YesNoNo Answer
7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure? * YesNo
7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy? YesNoNo Answer
7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week? YesNoNo Answer
7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs? YesNoNo Answer
8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia? * YesNo
8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting? YesNoNo Answer
8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)? YesNoNo Answer
9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event? * YesNo
9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments) YesNoNo Answer
9b. Do you have any impairment in walking or mobility? YesNoNo Answer
9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months? YesNoNo Answer
10. Do you have any other medical condition not listed above or do you have two or more medical conditions? If No please read the recommendations below: * YesNo
10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months? YesNoNo Answer
10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)? YesNoNo Answer
10c. Do you currently live with two or more medical conditions? YesNoNo Answer
PLEASE LIST YOUR MEDICAL CONDITION(S)AND ANY RELATED MEDICATIONS HERE:
If you answered NO to all of the FOLLOW-UP questions above about your medical condition, you are ready to become more physically active - check the PARTICIPANT DECLARATION below:
It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.
You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.
As you progress, you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.
If you answered YES to one or more of the follow-up questions about your medical condition: You should seek further information before becoming more physically active or engaging in a fitness appraisal. You should complete the specially designed online screening and exercise recommendations program - the ePARmed-X+ at www.eparmedx.com and/or visit a qualified exercise professional to work through the ePARmed-X+ and for further information
Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.
In consideration of Protrainerlive granting permission for you to participate, all persons participating in activities agree to release and discharge Protrainerlive, its owner, staff, and volunteers from and against all claims and proceedings made in respect to any cost, losses, damages or injuries by reason of participating in such activities or by reason of the provision of medical services. All participants are physically and mentally capable to participate in activities outlined by Protrainerlive.
PARTICIPANT DECLARATION If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.
I have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.
If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form.
I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.
I have read, understood and agreed to the terms of the agreement above. The submitted information is accurate to the best of my knowledge. Check this box to confirm. * Name: * Date (YYYY-MM-DD): *
Please leave this field empty.
