Pre Exercise Questionnaire.xlsx
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Medical Questionnaire
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Please answer the following questions accurately , truthfully and giving any further details if necessary.
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Positive answers to the questions below may require a doctors referral.
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Name:Contact Number:
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D.O.B:Emergency Contact:
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YESNO
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Has your doctor ever said that you have a heart condition?
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Do you feel pain in your chest when you do physical activity?
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Do you lose balance because of dizziness or ever lose consciousness?
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Have you had or do you have high or low blood pressure?
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Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
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Do you know of any reason why you should not undertake exercise?
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(Women) are you pregnant or recently had a baby?
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Do you have any of the following impairments or health conditions? YESNO
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Visual impairment
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Hearing Impairment
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Physical Impairment
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Learning Impairment
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Mental Health Condition
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Health Condition
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Multiple Impairment
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If you answered ‘yes’ to any questions please give further details:
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If your health changes, altering the responses you would give to these questions you must seek further medical advice
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I have completed the health questionnaire honestly and agree to seek a doctors referral if necessary or requested to do so.
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Signed:Date:
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www.GorillaPT.com
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