"*" indicates required fields Name* First Last Email* Preferred phone number*Date of Birth* DD slash MM slash YYYY Age (in years)*Please enter a number from 18 to 100.Type of arthritis*OsteoarthritisRheumatoid ArthritisPsoriatic ArthritisAnkylosing SpondylitisGoutOther Autoimmune Condition (e.g. Lupus)UndiagnosedNot KnownMedical Clearance1. Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?* Yes No When did this occur (Month, Year)? Has it been suitably diagnosed and/or resolved or is it requiring ongoing management?*Date of Event (MM/YYYY)Detailed summary of the eventResolved or Ongoing Add Remove2. Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?* Yes No As you answered Yes, hAs you answered Yes, has this occurred in the last 1-3months and are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. diabetes, cardiorespiratory disorder or other)?* 3. Do you ever feel faint, dizzy or lose balance during physical activity/exercise?* Yes No As you answered Yes, has you answered Yes, has this occurred in the last 1-3months and are you aware of the (potential) cause or condition that may be attributed to this experience (e.g. diabetes, cardiorespiratory disorder or other)?* 4. Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?* Yes No As you answered Yes, do you require any medication to assist you during exercise (e.g. ventilator, reliever etc)* 5. If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?* Yes No As you answered Yes:*Are you currently taking any medication that is designed to bring this into control? (Yes/No)If so what medication are you taking? Add RemovePlease click the + to list additional medication6. Do you have any other CURRENT conditions that may require special consideration for you to exercise? (This many include previous or current injuries/conditions -e.g. recent/current fractures, cancer diagnosis/treatment, neurological conditions, etc)* Yes No As you answered Yes, please provide a brief but detailed summary of your recognised special consideration (e.g. time of event, nature and whether it is resolved or ongoing*Date of Event (MM/YYY)Detailed summary of special considerationResolved or Ongoing Add RemovePlease click the + to list additional medicationAs you answered Yes, please provide a brief but detailed summary of your recognised special consideration (e.g. time of event, nature and whether it is resolved or ongoing*Date of Event (MM/YYY)Detailed summary of special considerationResolved or Ongoing Add RemovePlease click the + to list additional medication7. Please reflect on your health during the current periods, and note any health developments (e.g., injuries, condition diagnoses) that you think may be relevant to your participation in our exercise (Note: if no major/significant issues have arisen please write N/A)Last 6 months:* Last 12 months:* Last 3 years:* 8. Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. For intensity guidelines download the Exercise Intensity Guide.Frequency (How many sessions per week, per level of exercise?)*LightModerateVigorous/HighDuration (How many minutes per week, per level of exercise?)*LightModerateVigorous/HighTotal minutes per week*Total minutes = (frequency x duration)9. Have you had any falls in the past 12 months? If so, how many?* None 1 fall 2 falls 3 or more 10. When walking and turning, are you unsteady or at risk of losing your balance?* No unsteadiness observed Yes, minimally unsteady Yes, moderately unsteady (needs supervision) Yes, consistently and severely unsteady (needs constant hands-on assistance) 11. Are you experiencing any CURRENT neurological concerns such as headache, dizziness, weakness, numbness, tingling, tremors, loss of balance, loss of memory or decreased coordination?* Yes No As you answered Yes:*Is it currently affecting you in your day to day?Has it been attributed to a previously diagnosed conditionAre you undergoing current investigations into why it is occurring? Add Remove12. Have you been admitted to hospital for any acute complication within the last 6 weeks?* Yes No As you answered Yes, please provide more detail* Arthritis NSW Exercise Participation WaiverREAD CAREFULLY BEFORE SIGNING In consideration for my participation in “The program” hosted by Arthritis NSW. I hereby RELEASE, WAIVE, DISCHARGE, AND COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND HOLD HARMLESS for any and all purposes SPONSOR, Arthritis NSW and their respective officers, servants, agents, volunteers, or employees (herein collectively referred to as RELEASEES) FROM ANY AND ALL LIABILITIES, RESPONSIBILITIES, CLAIMS, DEMANDS, CAUSES OF ACTION OR INJURY, INCLUDING DEATH, that I may sustain or to any property belonging to me whether caused by the negligence of the RELEASEES or otherwise, while participating in the Program, or while in, on or upon the premises where the Program is being conducted.Consent* I believe that to the best of my knowledge, all of the information I have supplied within this screening tool is correct.Consent Date* DD slash MM slash YYYY NameThis field is for validation purposes and should be left unchanged.
