Chris Anastasios Exercise Physiology

Medical Screening Form

Patient details:

Name:

Date of Birth:

Gender: MaleFemale

STAGE 1 (COMPULSORY)

AIM: to identify those individuals with a known disease, or signs or symptoms of disease, who may be at a higher risk of an adverse event during physical activity/exercise. This stage is self administered and self evaluated.

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke? YesNo

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

Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance? YesNo

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

If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months? YesNo

Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity/exercise? YesNo

Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? YesNo

IF YOU ANSWERED 'YES' to any of the 7 questions, please seek guidance from your GP or appropriate allied health professional prior to undertaking physical activity/exercise

IF YOU ANSWERED 'NO' to all of the 7 questions, and you have no other concerns about your health, you may proceed to undertake light-moderate intensity physical activity/exercise

STAGE 2 (OPTIONAL)

AIM: To identify those individuals with risk factors or other conditions to assist with appropriate exercise prescription. This stage is to be administered by a qualified exercise professional.

Risk Factors

Age: Gender: MaleFemale

≥ 45yrs Males or ≥ 55yrs Females
+1 risk factor

Family history of heart disease (eg: stroke, heart attack)

Relative	Age

If male < 55yrs = +1 risk factor
If female < 65yrs = +1 risk factor
Maximum of 1 risk factor for this question

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

If currently smoking, how many per day or week?

If yes, (smoke regularly or given up within the past 6 months) = +1 risk factor

Describe your current physical activity/exercise levels:

	Sedentary	Light	Moderate	Vigorous
Frequency sessions per week
Duration minutes per week

If physical activity level < 150 min/ week = +1 risk factor
If physical activity level ≥ 150 min/ week = -1 risk factor
(vigorous physical activity/ exercise weighted x 2)

Your height (cm) Your weight (kg)

BMI = weight (kg) / height (m)^2
BMI ≥ 30 kg/m2 = +1 risk factor

Have you been told that you have high blood pressure? YesNo

If yes, = +1 risk factor

Have you been told that you have high cholesterol? YesNo

If yes, = +1 risk factor

Have you been told that you have high blood sugar? YesNo

If yes, = +1 risk factor

STAGE 2 Total Risk Factors

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

If yes, provide details

Are you currently taking a prescribed medication(s) for any medical conditions(s)? YesNo

If yes, what is the medical condition(s)?

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

If yes, provide details (how many months pregnant or postnatal?).

Do you have any muscle, bone or joint pain or soreness that is made worse by particular types of activity? YesNo

If yes, provide details

STAGE 3 (OPTIONAL)

AIM: To obtain pre-exercise baseline measurements of other recognised cardiovascular and metabolic risk factors. This stage is to be administered by a qualified exercise professional. (Measures 1, 2 & 3 – minimum qualification, Certificate III in Fitness; Measures 4 and 5 minimum level, Exercise Physiologist*).

	Results		Risk Factors
1. BMI (kg/m2)		BMI ≥ 30 kg/m2 = +1 risk factor
2. Waist girth (cm)		Waist > 94 cm for men and > 80 cm for women = +1 risk factor
3. Resting BP (mmHg)		SBP ≥140 mmHg or DBP ≥90 mmHg = +1 risk factor
4. Fasting lipid profile* Total cholesterol HDL Triglycerides LDL		Total cholesterol ≥ 5.20 mmol/L = +1 risk factor HDL cholesterol >1.55 mmol/L = -1 risk factor HDL cholesterol < 1.00 mmol/L = +1 risk factor Triglycerides ≥ 1.70 mmol/L = +1 risk factor LDL cholesterol ≥ 3.40 mmol/L = +1 risk factor
5 Fasting blood glucose*		Fasting glucose ≥ 5.50 mmol = +1 risk factor
STAGE 3 Total Risk Factors

RISK STRATIFICATION

Total stage 2
or
Total stage 3
Plus stage 2 (Q1 - Q4)

≥ 2 RISK FACTORS – MODERATE RISK CLIENTS Individuals at moderate risk may participate in aerobic physical activity/exercise at a light or moderate intensity (Refer to the exercise intensity table on page 2)

< 2 RISK FACTORS – LOW RISK CLIENTS Individuals at low risk may participate in aerobic physical activity/exercise up to a vigorous or high intensity (Refer to the exercise intensity table on page 2)

Note: If stage 3 is completed, identified risk factors from stage 2 (Q1-4) and stage 3 should be combined to indicate risk. If there are extreme or multiple risk factors, the exercise professional should use professional judgement to decide whether further medical advice is required.