STADIUM
Adult Pre-Exercise Screening Tool
Given Name:
Surname:
Date of Birth:
Address:
Town:
Postcode:
E-mail Address:
Contact Phone:
(A/H):
(B/H)
Emergency Contact Name:
Contact Phone:
(Mobile)
Relationship:
(A/H):
(B/H)
(Mobile)
How did you hear about the programs offered at the Stadium:
Health professional
Community group
Advertisement
Word of mouth
Other (please list)
Adult Pre-Exercise Screening Tool
AIM: to identify those individuals with a known medical condition, or signs or symptoms of a medical condition, who may be
at a higher risk of an adverse event during physical activity/exercise.
Please circle response
1.
Are you currently pregnant or have you given birth in the past eight weeks?
I am currently
weeks/months prenatal/postnatal (please circle).
Medical clearance not required.
Yes
No
1.
Has your doctor ever told you that you have a heart condition or have you ever
suffered a stroke?
Yes
No
2.
Do you ever experience unexplained pains in your chest at rest or
during physical activity/exercise?
Yes
No
3.
Do you ever feel faint or have spells of dizziness during physical
activity/exercise that causes you to lose balance?
Yes
No
4.
Have you had an asthma attack requiring immediate medical
attention at any time over the last twelve months?
Yes
No
5.
If you have diabetes (type one or type two) have you had trouble controlling
your blood glucose in the last three months?
Yes
No
6.
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?
Yes
No
7.
Do you have any other medical condition(s) or allergies that we need to know
about or may make it dangerous for you to participate in physical
activity/exercise?
Yes
No
IF YOU ANSWERED ‘YES’ to any of the above questions, excluding question one,
you will be required to obtain a medical clearance from your GP prior to undertaking
physical activity/exercise.
IF YOU ANSWERED ‘NO’ to the above questions, and you have no other concerns about your
health, you may proceed with physical activity/exercise.
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Adult Pre-Exercise Screening Tool
Adult Pre-Exercise Screening Tool
1.
Age
Gender
2.
Family history of heart disease (eg: stroke, heart attack)
Relative
3.
Age
Relative
Age
Father
Mother
Brother
Sister
Son
Daughter
Do you smoke cigarettes on a daily or weekly basis or have
You quit smoking in the last 6 months?
Yes
No
If currently smoking, how many per day or week?
4.
Describe your current physical activity/exercise levels:
Sedentary
Light
Moderate
Vigorous
Frequency
sessions per week
Duration
minutes per week
5.
Have you been told that you have high blood pressure?
Yes
6.
Have you been told that you have high cholesterol?
Yes
7.
If yes, please provide details
No
Have you spent time in hospital (including day admission) for any
medical condition/illness/injury during the last 12 months?
Yes
9.
No
Have you been told that you have high blood sugar?
Yes
8.
No
No
Are you currently taking a prescribed medication(s) for
any medical condition(s)?
Yes
If yes, what is the medical condition(s)?
No
10. Do you have any muscle, bone or joint pain or soreness that is
made worse by particular types of activity?
Yes
If yes, please provide details
If yes, please provide details
No
I believe that to the best of my knowledge, all of the information I have supplied within this tool is correct.
I will notify stadium staff or the program instructor of any changes to the information provided.
Signature
Date
INDEMNITY WAIVER
In consideration of the acceptance of participating in an Active Living program:
The Applicant agrees to indemnify and to keep indemnified, the Greater Shepparton City Council,
servants and agents, and each of them against all actions, costs, claims, charges, expenses,
penalties, demands and damages whatsoever which may be brought or made with the Applicant’s
performance or purported performance of its obligations under this hiring agreement and be
directly related to the negligent acts, errors or omissions of the Applicant.
The Applicant’s liability to indemnify the Greater Shepparton City Council shall be reduced
proportionally to the extent that any act or omission of the Greater Shepparton City Council, its
servants or agents, contributed to the loss or liability.
The Applicant agrees to comply with all the rules, regulations and instructions in relation to the
hire/use of the Sports Stadium.
I have read, understood, acknowledge and agree to the above indemnity details which are valid for
the duration of my participation in stadium program/s.
Signature:
Date:
PRIVACY STATEMENT
The personal information contained in this document is to provide contact information and medical
details for individuals wishing to utilise Shepparton Sports Stadium facilities. This information may
be disclosed to other areas of Sports Stadiums, Council, medical practitioners or other third parties
should there be an issue or medical emergency, and in accordance of the Information Privacy Act.
o you give permission for the class instructor or stadium staff to discuss your medical history with
your Doctor/Therapist if necessary?
Yes
No
PHOTOGRAPH PERMISSION
Photographs taken may be widely distributed throughout the community and the media. Local or
other media may also take their own photograph, where necessary, for publicity and promotional
purposes.
Do you give permission for the use of photographs of yourself by the Shepparton Sports Stadium
and Greater Shepparton City Council for promotional and publicity purposes?
Yes
No
PROGRAM DESCRIPTION
Tuesday Strength Training
A slower, chair based & standing strength training program which includes functional exercises to
increase the strength and confidence for activities in daily life. Focus is on strength training but the
program also incorporates flexibility, mobility, posture, gait and balance.
This class is suitable for older adults, people with health conditions and those new or returning to
exercise.
Wednesday Strength Training
A combination of both standing and chair based exercises, styled with options to cater for all
fitness levels. The chair based exercises focus on light weights to develop and maintain muscle
endurance. Light aerobic footwork is included to sharpen agility and co-ordination. Balance and
stability challenges are introduced throughout the class, which are designed from basic Tai Chi,
Yoga and Pilates concepts. This is aimed to improve strength and flexibility in the muscles
required for day to day living.
Friday Strength Training
A circuit weight based program which focuses on strength and functional exercises to increase the
strength and confidence for activities in daily life. This program incorporates balance, hand-eye coordination and other day to day movements to advance the individuals balance and mobility.
This class is suitable for any individual as it can easily be modified to suit all needs and abilities.
Active for Life
Active for Life is an ideal exercise program for people who are looking to resume exercising after
injury or illness or for people that are new to exercise and need to build up their fitness. It is also
structured to suit people that have completed rehabilitation at the Goulburn Valley hospital and
wish to continue exercising to maintain strength and fitness. This program involves both aerobic
and strength training exercises and it is supervised by a qualified fitness instructor, with clients
encouraged to self-monitor as taught in the rehabilitation program.
Monday Tai Chi
Tai Chi is a series of slow, controlled movements and postures for people who wish to improve
their health. This class focuses exclusively on performing the body movements with great poise so
that the mind achieves a calm and empty clarity. This program is ideal for any individual that
wishes to improve their mental and physical health.
Social Badminton
Badminton is a fun and social sport with several health advantages such as strength, mobility,
flexibility and muscular endurance.
Keen Agers - Recreational table tennis
The sport offers good cardiovascular exercise and health benefits to players of any age and fitness
level. The risk of injury is low and the intensity is manageable for most people
Fun, Fitness and Self Defence Self Defence
Is an educational and active program providing participants with new skills and a fun learning
environment. The increased mobility, extra strength and balance achieved by a Self Defence
program often leads to many health benefits such as increased energy, improved confidence and
self esteem.
All of these programs have been structured to provide mild-moderate intensity exercise.
MEDICAL CLEARANCE
Participants Name:
Please tick the program(s) you wish to participate in (full description included on the previous
page):
Tai chi
Keenagers Recreational Table Tennis
Strength Training for Older Adults
Social Badminton
Back in the Game
Active for Life
Fun, Fitness & Self Defence
Name of Doctor:
Address:
Contact number:
It is my opinion that this person is medically able to participate in the programs offered at the
Shepparton Sports Stadium.
Further comments or risks if any:
Doctors Signature
Date