Pre-Screening Questionnaire | Online Health Screening

Pre-screening questionnaire.

Hi there Paapa Kweku here. My team and I are excited to become your Trainers. Utilising our expertise, we will support you on your journey to unlock your potential to unearth the best version of yourself. Please find below our pre-screening questionnaire. It’s aim is to give us a general understanding of your current state of health. If you indicate a YES to any question posed, please include some details about it in the space provided below.

Emergency Contact. (ideally, the emergency contact should be different to the parent/guardian):

Please note: In case of a medical emergency, an ambulance may be used to transport your child to the nearest medical treatment service.

Pre-screening Questions

Has your child had surgery in the previous 12 months?

Yes No

If so, please give details.

Does your child take any medications?

Yes No

If so, please name medication and condition taken for. Includes asthma medication and diabetes medication

If your child is taking any medication, please state if there are any side effects experienced as a result of taking this medication.

Are you aware of any medical reason/condition which might prevent your child from participating in an exercise program?

Yes No

If Yes, please give details.

Does your child have, or has your child had any of the following: (please tick any applicable)

A heart condition High blood pressure High cholesterol Unexplained coughing during or after exercise Breathing problems or shortness of breath (for example, asthma, emphysema)

If you ticked any of the above, please give details.

Does your child experience or has your child ever experienced any of the following? (please tick any applicable)

Epilepsy or seizures/convulsions Fainting or Dizzy spells Heat stroke/heat-related illness Increased bleeding tendency/haemophilia Other (please specify):

If you ticked any of the above, please give details.

Does your child have, or has your child had an eating disorder?

Yes No

In the last six months, has your child had any muscular, joint or bone pain while exercising?

Yes No

If yes, please explain and indicate where the pain has occurred (eg. ‘pain in the back of the right heel’ ):

Has a doctor treated this pain?

Yes No

Has your child broken any bones or suffered injury to their bones in the last 12 months

Yes No

Please give details.

Is your child allergic to food, medications, pollens or other allergens or specific environment?

Yes No

If yes, please explain what causes have been identified with this/these allergy/ies

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

Yes No

Are these or any other injuries aggravated by exercise?

Yes No

Please give details.

Does you child currently exercise? and if so, how often

No once a week 2-3 times a week 4 sessions a week +

What type of exercises does your child currently do?

Risk and Limitation of Liability

Students must get their parents or guardians’ approval before accessing our program. Students with their parents must consult their physician prior to starting our program or if they have any medical condition or injury that contraindicates physical activity.

• Students must have a full physical examination if they are sedentary or if they have high cholesterol, high blood pressure, diabetes or are overweight. If they meet any of the above requirements, a scheduled examination is requested
• If students have any injuries or medical conditions that would prevent them from performing any type of exercise, it is important they talk to their doctor about it. Their doctor understands their health and physical capacity.
• The meals and recipes shared as part of our program are not a substitute for independent professional advice. They are not intended to be used as medical advice nor are they intended to be used to diagnose, treat, cure or prevent any disease. Each student is different. It’s important you discuss any dietary suggestions with your doctor to ensure it is right for you. To obtain the most accurate representation of the nutritional information in a given recipe, you should calculate the nutritional information with the actual ingredients used in your recipe, using your preferred nutrition calculator. Students and parents are responsible for ensuring that any nutritional information provided is accurate, complete, and useful.

To the extent permitted by law, Healthy Teens and Naturally Trim excludes any liability, tort, statute or in any other way for any injury, damage or loss of any kind whatsoever (including, without limitation, any liability for direct, indirect, special or consequential loss or damage), sustained by staff undertaking our fitness programs, or for any costs, charges or expenses incurred by staff, arising from or in connection with this program and/or services/products provided by Naturallytrim.

As part of our Healthy Teens program, your child may be photographed and/or videotaped to highlight what we do. With your consent, the photograph and/or video may be used by Healthy Teens in promotions such as brochures, videos, on our URL or the school’s website. I give permission for my child’s photograph/Video to be used by Healthy Teens or included on the school’s website.

Yes I Consent No I do not consent

Declaration

I confirm that to the best of my knowledge the information given within this document is correct, and understand that it will be treated with strictest confidence by Healthy Teens (and by those acting for and on behalf of Naturally Trim) for services that I may wish to engage in now and in the future.

Use o f the school gym

I have read and understood the terms and conditions of the use of the school gym. I fully understand that adherence to regulations and guidelines is to ensure a safe and respectful environment for all students.

Parents / Guardian's Name