Screening Questionnaire Name(Required) First Last Phone(Required)Email(Required) Date of Birth(Required) DD slash MM slash YYYY 1. Do you regularly undertake a minimum of 3x 30min / week moderate to high intensity exercise, e.g. triathlon, cycling, running, swimming?(Required) Yes No Please describe in detail – Type of ExerciseMondayTuesdayWednesdayThursdayFridaySaturdaySundayPlease describe in detail – Intensity of ExerciseMondayTuesdayWednesdayThursdayFridaySaturdaySundayPlease describe in detail – Length of ExerciseMondayTuesdayWednesdayThursdayFridaySaturdaySunday2. Do you experience prolonged muscle soreness/ pain after a training session? Describe your level of pain on a scale 0‐10Level of muscle soreness/ pain VAS PAIN Scale 0‐10MondayTuesdayWednesdayThursdayFridaySaturdaySundayRecovery TimeOn average, how long does it take you to fully recover = no pain/ muscle soreness?3. ESSA (Exercise and Sports Science) Adult pre‐exercise screening tool1. Has your doctor ever told you that you have a heart condition or have your ever suffered a stroke?(Required) Yes No 2. Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?(Required) Yes No 3. Do you ever feel faint or have spells of dizziness during physical activity/exercise that causes you to lose balance?(Required) Yes No 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?(Required) Yes No 5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood glucose in the last 3 months?(Required) Yes No 6. Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in high intensity physical activity?(Required) Yes No 7. Do you have any other medical condition(s) that may make it dangerous for you to participate in high intensity exercise?(Required) Yes No Additional CommentsCAPTCHA
