Pre-screening Health Questionaire

Kindly take the time to fill out the health and fitness questionnaire below. It's purpose is to give healthy teens an indication of your current state of health. Please be as detailed as you can. The more information you provide, the clearer your state of health will be for us to assess.

Your name (this field required)

Your e-mail address (this field required)

Gender (this field required)
MaleFemale

What is your age?

What is your height in centimeters?

What is your weight in kilograms?

What year level are you in? (this field required)
Year 7Year 8Year 9Year 10Year 11Year 12I am a TeacherI am a parent

How would you describe your current physical lifestyle?
Little to no exerciseLight exercise (1–3 days per week)moderate exercise ( 3-5 days per week)Strenuous exercise (6–7 days per week)

How would you best describe your body type?
Ectomorph - your body type is thin with very little body massSkinny with body fat - Your body type is slim with adipose tissue on topMuscular/toned with a few kilos to lose - It's time to shred/tone upMesomorph - Your body is muscular/toned. You've trained in the pastModerate - Your body is framed with an adequate amount of body fat for your buildEndomorph - You have a soft round build with a high proportion of fat tissueObese - By strict definition you are overweight with an abundant amount of body fat

Have you ever had a heart attack, coronary revascularization surgery or a stroke?
NoYes

Has your doctor ever told you that you have heart trouble or vascular disease?
NoYes

Has your doctor ever told you that you have a heart murmur?
NoYes

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

Do you ever get pains in your calves, buttocks or at the back of your legs during exercise which are not due to soreness or stiffness?
NoYes

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

Do you experience swelling or accumulation of fluid about the ankles?
NoYes

Do you ever get the feeling that your heart is suddenly beating faster, racing or skipping beats, either at rest or during exercise?
NoYes

Do you have chronic obstructive pulmonary disease, interstitial lung disease, or cystic fibrosis?
NoYes

Have you ever had an attack of shortness of breath that developed when you were not doing anything strenuous, at any time in the last 12 months?
NoYes

Have you ever had an attack of shortness of breath that developed after you stopped exercising at any time in the last 12 months
NoYes

Have you ever been woken at night by an attack of shortness of breath at any time in the last 12 months?
NoYes

Do you have diabetes [type I or type II]
NoYes

If so, do you have trouble controlling your diabetes?
NoYes

Do you have any ulcerated wounds or cuts on your feet that do not seem to heal?
NoYes

Do you have any liver, kidney or thyroid disorders?
NoYes

Do you experience unusual fatigue or shortness of breath with usual activities?
NoYes

Do you have any other medical conditions that may make it dangerous for you to participate in physical activity/exercise?
NoYes

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? (this field required)
NoYes

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 required)
NoYes

Are you pregnant? (this field required)
NoYes

Is there any other physical reason or medical conditions or are you taking any medication(s) Which could prevent you from under taking an exercise program, or that you are concerned about? (this field required)
NoYes

If you indicated a Yes to any of the questions above, kindly provide me with some more information about your condition

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