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Student No. (if known)

First Name

Last Name

Date of Birth

Gender
Male
Female

Telephone

Email Address

Has your doctor ever told you that you should only exercise with his/her consent?
Yes
No

Do you have a heart condition?
Yes
No

Do you have pain in your chest when you do a physical activity?
Yes
No

In the past month, have you had chest pain when you were not doing physical activity?
Yes
No

Do you suffer from asthma or any other respiratory problems?
Yes
No

Do you ever lose your balance because of dizziness or do you ever lose consciousness?
Yes
No

Do you have a bone or joint condition that be could be made worse by exercise?
Yes
No

Please give details

Are you currently taking prescribed medication for a medical condition?
Yes
No

Are you compliant with the medication?
Yes
No

Please list the medications you are taking

Do you have replacement joints?
Yes
No

Do you get pain in the calf when walking?
Yes
No

Does it go away if you continue to walk?
Yes
No

Have you fallen more than twice in the last year?
Yes
No

How many times have you fallen?

Can you stand freely for 30 seconds without any aid?
Yes
No

Do you use a balancing aid?
Yes - all of the time
Yes - some of the time
No - not at all

Do you use public transport?
Yes
No

Do you have strength, balance, or stability problems when going up and down stairs?
Yes
No

Do you have strength, balance, or stability problems when going up and down slopes?
Yes
No

Do you have strength, balance, or stability problems when getting in/out of a bath?
Yes
No

Do you have strength, balance, or stability problems when getting in/out of a chair?
Yes
No

Do you have strength, balance, or stability problems when gardening or cleaning?
Yes
No

Do you know, through your own experience or a doctor’s advice, why you should not participate in an exercise programme?
Yes
No

Please give details

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