Pre Exercise Health Screening Form - Australian Institute of Martial Arts

PRE-EXERCISE HEALTH SCREENING FORM

Participant Health & Exercise Screening

Before participating in AIMA physical activity programs, participants are asked to complete this Pre-Exercise Health Screening (PEHS) Form.

The purpose of the form is to provide AIMA with relevant information about your current health, physical condition, previous injuries or surgery, pain, mobility and other factors that may need to be considered when participating in physical activity.

The information provided is treated as confidential and is used to help the instructor plan and deliver appropriate activities, modifications and levels of participation.

Each participant must complete their own PEHS Form. For participants under 18 years of age, the form must be completed and acknowledged by a parent or legal guardian as required.

If your health or physical circumstances change, you should update your PEHS information and advise your instructor before participating.

This form also includes AIMA's Participant Waiver, Acknowledgement and Indemnity & Release Consent relating to participation in AIMA physical activities.

Completing this form does not replace medical advice or clearance where this is required. If you have any concerns about your ability to participate safely in physical activity, please consult your doctor or appropriate health professional before commencing.

What happens after you submit the form?

Once your form has been submitted, AIMA will review the information provided as part of our participant health and safety process.

If further information or clarification is required, AIMA may contact you before participation.

Once your submission has been reviewed and you have received confirmation from AIMA, you may proceed with your relevant AIMA activity or class arrangements.

If you do not receive confirmation or have any questions about your submission, please Contact AIMA.

Pre-Exercise Health Screening

Please Fill Out The PEHS Form and Submit

Participant's First and Last Name*
Date of Birth*
Mobile*
Email*
Enter Email Confirm Email
Emergency Contact Ph*
Emergency Contact Name*
Relationship to Participant*
Please describe any areas where you frequently experience pain or discomfort.*
What aggravates pain?*
What alleviates pain?*
Pain Scale*
1. Have you recently experienced unusual spinal, joint or muscular pain or discomfort?*
2. Has your Doctor ever told you that you have a heart condition or have you ever suffered a stroke?*
3. Do you ever experience unexplained pains in your chest at rest or during physical activity / exercise?*
4. Do you ever feel faint or experience spells of dizziness during exercise that cause you to lose balance?*
5. Have you had an Asthma Attack requiring immediate medical attention at any time in the last 12 months?*
6. If you have Diabetes Type I or Type II, have you had trouble controlling your blood glucose levels over the last 3 months?*
7. Do you have any diagnosed muscle, bone or joint problems that you have been advised could be made worse by participating in physical activity or exercise?*
8. Have you had any major or recent surgery within the past 12 months?*
9. Are you currently taking any medication?*
10. Do you have any other medical conditions or injuries that we should be aware of, or any conditions that may make it unsafe for you to participate in physical activity?*
PARTICIPANT HEALTH SCREENING & ACKNOWLEDGEMENT

This Pre-Exercise Health Screening Form is completed by the participant to provide AIMA with information relevant to their participation in physical activity. The information provided is used to help AIMA and its instructors identify health, mobility or other considerations that may require appropriate modifications, additional precautions or further advice before participation. If you answer “Yes” to any of the health screening questions, or if you have any concerns about your ability to participate safely in physical activity, you should seek appropriate medical advice or clearance before commencing or continuing physical activity. You should also inform your instructor of any relevant health condition, injury, medication or change in your physical condition that may affect your participation. I confirm that, to the best of my knowledge, the information I have provided in this form is accurate and complete. I understand that it is my responsibility to inform AIMA and my instructor of any relevant changes to my health or physical condition. I understand that physical activity involves inherent risks, and that I am responsible for participating within my own capabilities and following reasonable instructions provided by the instructor. I understand that I may modify, pause or discontinue an activity if I experience pain, discomfort, dizziness, illness or any other concern. I acknowledge that AIMA and its instructors will take reasonable steps to provide appropriate instruction and maintain a safe training environment, but that no physical activity can be completely free of risk.
Date*
DD slash MM slash YYYY

This date records the day the participant, or parent/guardian where applicable, completed and signed this form.
Your Signature*
Full Name of Participating Member or Parent/ Guardian if Applicable*
If the participant is under 18 years of age, a parent or legal guardian must complete and sign this form on their behalf.
INDEMNITY & RELEASE CONSENT

Agreement for participation in AIMA physical activities and training programs. For the purposes of this agreement, “AIMA” refers to Australian Institute of Martial Arts. “Trainer” refers to AIMA and any instructor, trainer or other person authorised by AIMA to conduct or assist with the Activity. “Activity” refers to participation in AIMA physical activities, training programs, instruction and related general advice.
• The information obtained in this document will be treated as privileged and confidential.
• I acknowledge that it is a condition of participating in this activity that I do so at my own risk’
• I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly and indirectly associated with the trainer or program, against all liability (including liability for their negligence and the negligence of others) claims, damage, loss or injury (including death) demands and proceedings arising out of or connected with my participation in this.
• This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and restricts me from suing or otherwise claiming against the Trainer, presently or at any future time, for damage, loss or injury that may occur to myself or my property as a result of participating in this activity
• I confirm that I have provided accurate and complete information about any health conditions, injuries, disabilities or physical limitations that may affect my participation in the Activity. I will seek appropriate medical advice where I have concerns about my ability to participate safely.
• I understand that participation in the Activity involves physical activity and that I must inform the Trainer of any medical condition, injury or impairment that may affect my ability to participate safely. If my health or physical condition changes, I will inform the Trainer before continuing to participate.
• I am voluntarily entering into this release and acknowledge that I have been given the opportunity to seek independent legal advice before agreeing to its terms.
• I confirm that I have had the opportunity to ask questions about the Activity and that any questions I have raised have been answered to my satisfaction. I understand that I may withdraw from participation in the Activity at any time. Any separate membership, program, payment or other contractual terms that apply to my participation remain subject to their applicable terms and conditions
• I confirm that I have read this document and understand its terms. If I am completing this agreement as the parent or legal guardian of a participant under 18 years of age, I agree to these terms on behalf of myself and the participant, to the extent permitted by law.
Date*
DD slash MM slash YYYY

This date records the day the participant, or parent/guardian where applicable, completed and signed this form.
Your Signature*
Participant's Full Name or Parent/Guardian's Full Name if Applicable*
If the participant is under 18 years of age, a parent or legal guardian must complete and sign this form on their behalf.
Date*
DD slash MM slash YYYY

This date records the day the participant, or parent/guardian where applicable, completed and signed this form.