Ambulance Victoria’s Pre-Program Questionnnaire

Bodycare | Healthworks

Personal Details

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Medical History

Has your doctor ever told you that you have a heart condition?
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Have you ever suffered a stroke?
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Do you experience unexplained pains in your chest at rest or during physical activity?
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Do you feel faint or have spells of dizziness during physical activity that causes you to lose your balance?
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Have you had an asthma attack requiring immediate medical attention at any time over the past 12 months?
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If you have diabetes (type 1 or type 2), have you had trouble controlling your blood glucose in the last 3 months?
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Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity?
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Do you have any medical condition(s) that may make it dangerous for you to participate in physical activity?
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Are you currently taking any medication?
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If yes, what medication(s) is it and for what condition(s)?
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Are you pregnant or have you given birth in the last 12 months?
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If you answered YES to any of the above questions, please discuss this with the allied health professional, so that they can assess your medical and physical suitability for this program.
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Previous Injury History

Have you been injured?
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If so, what injury and how was it sustained?
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Have you experienced any injuries in the past 12 months?
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If so, what injury and how was it sustained?
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Do you have any pain now?
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If so, please specify where?
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Do you receive regular physiotherapy, osteopathy, massage or chiropractic treatment?
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Lifestyle Behaviours

Do you smoke?
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If so, on average, how many cigarettes per day?
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Do you drink alcohol?
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If so, on average, how many days per week?
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How many times per week do you usually exercise?
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My current understanding of the benefits of physical activity are:
Where 0 = Very Poor and 10 = Excellent
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How would you rate your overall health and fitness?
Where 0 = Very Poor and 10 = Excellent
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What are 3 exercise goals you hope to achieve from the program?
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What are 3 lifestyle goals you hope to achieve from the program?
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Signed
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