Adult Pre-Exercise Screening Tool
Pre-Exercise Screening and Assessment Forms
This screening tool plays a vital role in ensuring the safety and effectiveness of fitness
programs by thoroughly identifying individuals who may require medical clearance before
participating in physical activities. By gathering comprehensive health and lifestyle details,
this tool enables trainers and clients to work collaboratively toward tailored exercise plans.
This process not only minimizes the potential risks associated with physical activities but
also fosters a positive and enjoyable fitness experience for all participants.
1. Pre-Exercise Screening Tool
Personal Details
• Name: ____________________
• Birthdate: _______________
• Phone: ___________________
• Email: ___________________
• Emergency Contact Name: _______
• Relationship to Contact: ____________
• Emergency Contact Phone: _________
Medical History
• Existing Conditions (check all that apply):
o Heart disease
o High blood pressure
o Diabetes
o Asthma
o Joint problems
o Other: ________________
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Adult Pre-Exercise Screening Tool
Lifestyle Details
• Smoking Status:
o Current smoker
o Former smoker
o Never smoked
• Alcohol Consumption:
o Regular
o Occasional
o None
• Activity Level:
o Sedentary (little or no physical activity)
o Active (some physical activity weekly)
o Highly Active (frequent, intense physical activity)
Current Medications
• List any medications you are currently taking: ________________
Past or Current Injuries
• Injury History (check one):
o Yes (Specify): ________________
o No
Medical Clearance
• Has a doctor ever advised you to avoid physical activity?
o Yes
o No
Signature: _______________ Date: _______________
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Adult Pre-Exercise Screening Tool
2. PAR-Q+ (Physical Activity Readiness Questionnaire)
The PAR-Q+ helps determine the individual’s readiness for physical activity by asking the
following critical health-related questions:
1. Do you have a heart condition or high blood pressure?
o Yes
o No
2. Do you experience chest pain during physical activity?
o Yes
o No
3. Have you had chest pain at rest within the last month?
o Yes
o No
4. Do you often feel dizzy or faint?
o Yes
o No
5. Do you have any bone or joint problems that could be worsened by physical
activity?
o Yes
o No
6. Are you currently taking medications for any chronic condition?
o Yes
o No
Signature: _______________ Date: _______________
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Adult Pre-Exercise Screening Tool
3. Fitness Goal Questionnaire
Understanding a client’s fitness goals is critical for developing a customized program. This
section captures the individual's specific aspirations and barriers to success.
Goals
• What are your primary fitness goals? (check all that apply):
o Weight loss
o Muscle gain
o Endurance improvement
o Flexibility enhancement
o General wellness
o Other: ________________
Motivation
• What motivates you to achieve these goals? ________________
Timeline
• Do you have a specific timeline for achieving these goals?
o Yes (Specify): ________________
o No
Obstacles
• What challenges or obstacles might prevent you from reaching your goals?
________________
Signature: _______________ Date: _______________
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Adult Pre-Exercise Screening Tool
4. Informed Consent
Acknowledgment and Agreement
By signing this informed consent form, you acknowledge that the information provided is
accurate to the best of your knowledge. You also accept the inherent risks associated with
physical activity and agree to notify your trainer of any changes in your health status.
• Participant Agreement:
o I understand and accept the risks of participating in a fitness program.
o I agree to provide accurate health information and update my trainer about
any relevant changes in my condition.
Participant Signature: _______________ Date: _______________
Trainer Signature: _______________ Date: _______________
