Pre-exercise Questionnaire GLC

The City of Busselton collects personal information to process this form and provide the requested services. Information may be used for related City business purposes or disclosed where authorised by law.

To learn how your personal information is handled, access the City’s Privacy Statement or contact the Privacy Officer at privacy@busselton.wa.gov.au.

Gender*This field is required.
STAGE 1 - COMPULSORY COMPLETION

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.

Please indicate Yes or No to below questions.

1. Has your doctor ever told you that you have a heart condition OR have you ever suffered a stroke?*This field is required.
2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?*This field is required.
3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?*This field is required.
4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*This field is required.
5. If you have diabetes (type I or type II) have you had trouble controlling your blood glucose in the last 3 months?*This field is required.
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?*This field is required.
7. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise?*This field is required.
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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

Referred for GP approval
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Please supply a copy of your medical clearance, if applicable.

Declaration - I believe that to the best of my knowledge, all of the information I have supplied is correct. I will notify staff if any of the above changes at any time, to assist with my exercise program and safety.*This field is required.
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