Information collection
I decided to use a lifestyle questionnaire to collect my information. The Human right act 1998 gives every individual the right to
respect for their private and family life, this includes their personal information that they may share. The data protection act
2018 controls how our personal information is used by organisations or businesses.
To protect the identity of the person for the purpose of this assignment I have changed the personal details so only I can
identify him using a code I have given for his date of birth. This has allowed me to use his information with his consent but also
protect confidential information such as his address and personal information that he has shared. To adhere to legislation, I
only have access to the original questionnaire, and it is in a locked cabinet that only I have access to, this has allowed me to
limit the access to the personal information included on the questionnaire and protect his identity.
HEALTH SCREENING
PRE-TRAINING HEALTH SCREENING QUESTIONNAIRE
Name Mr A Volunteer Gender: Male
Date of birth 030/030/02002
Address Exercise , health and lifestyle
Email
If you are between the ages of 15 and 69 and are intending to take part in physical activity or regular sport/exercise and you are
new to exercise, the questions below will give an indication as to whether you should consult a doctor before you start. If you
are over the age of 69 and you are not used to physical activity, you should consult your doctor first in any case. All information
you record on this form will be treated with utmost confidentiality, it will be stored in a secure place and made available to you
at any time.
Please state YES or NO
Q1 Has your doctor ever said you have a heart condition and/or should only participate in medically supervised physical
activity? No
Q2 Do you ever feel pain in your chest during physical activity? No
Q3 Have you experienced chest pains when not doing physical activity? No
Q4 Do you suffer with palpitations? No
Q5 Do you experience dizziness or fainting? No
Q6 Have you ever been told you have high blood pressure or are you taking medication for blood pressure or any other
heart condition? No
Q7 Do you have any existing bone or joint problem that could be made worse by physical activity? No
Q8 Do you experience shortness of breath during only mild exertion? No
Q9 Do you suffer from either asthma or diabetes mellitus? No
Q10 Are you currently taking any prescribed medication we need to be made aware of? If so, what?
No medication
Q11 Are you pregnant or have you given birth in the last 6 weeks? N/A
Q12 Have you recently undergone surgery or are you carrying any injury? No
Q13 Are you aware of any other reasons why you should not participate in physical exercise without medical supervision?
If so, what? No
If you have answered YES to any of Q1 to Q13, we will require you to obtain written consent from your doctor before agreeing
to undertake any form of fitness testing, physical activity, training or exercise with you. We suggest you talk to your doctor by
phone or in person before you begin becoming more physically active and certainly before you undertake any form of formal
fitness assessment. Tell your doctor about this questionnaire and which questions you answered YES to.
You may be able to do any activity you want as long as you begin slowly and build up gradually, or you may need to restrict your
activities to those which are safe for you. Talk with your doctor about the kinds of activity you wish to participate in and follow
his/her advice.
Please state YES or NO
Q14 Is your blood pressure known to be higher than average (over 120/80)? No
Q15 Is your level of cholesterol known to be high? No
Q16 Is there any history of coronary heart disease or coronary artery disease in your parents or siblings before the age of
55? No
On induction recheck - Blood pressure reading, Resting heart rate
If you have answered YES to two or more of Q14 to Q16, for safety reasons we will restrict any programme of exercise to a
moderate intensity unless you obtain written consent from your doctor to exercise at a higher intensity. Moderate intensity is a
level at which you are able to comfortably sustain exercise for up to at least 60 minutes (usually not exceeding 65 of your
maximal heart rate).
I decided to use a lifestyle questionnaire to collect my information. The Human right act 1998 gives every individual the right to
respect for their private and family life, this includes their personal information that they may share. The data protection act
2018 controls how our personal information is used by organisations or businesses.
To protect the identity of the person for the purpose of this assignment I have changed the personal details so only I can
identify him using a code I have given for his date of birth. This has allowed me to use his information with his consent but also
protect confidential information such as his address and personal information that he has shared. To adhere to legislation, I
only have access to the original questionnaire, and it is in a locked cabinet that only I have access to, this has allowed me to
limit the access to the personal information included on the questionnaire and protect his identity.
HEALTH SCREENING
PRE-TRAINING HEALTH SCREENING QUESTIONNAIRE
Name Mr A Volunteer Gender: Male
Date of birth 030/030/02002
Address Exercise , health and lifestyle
If you are between the ages of 15 and 69 and are intending to take part in physical activity or regular sport/exercise and you are
new to exercise, the questions below will give an indication as to whether you should consult a doctor before you start. If you
are over the age of 69 and you are not used to physical activity, you should consult your doctor first in any case. All information
you record on this form will be treated with utmost confidentiality, it will be stored in a secure place and made available to you
at any time.
Please state YES or NO
Q1 Has your doctor ever said you have a heart condition and/or should only participate in medically supervised physical
activity? No
Q2 Do you ever feel pain in your chest during physical activity? No
Q3 Have you experienced chest pains when not doing physical activity? No
Q4 Do you suffer with palpitations? No
Q5 Do you experience dizziness or fainting? No
Q6 Have you ever been told you have high blood pressure or are you taking medication for blood pressure or any other
heart condition? No
Q7 Do you have any existing bone or joint problem that could be made worse by physical activity? No
Q8 Do you experience shortness of breath during only mild exertion? No
Q9 Do you suffer from either asthma or diabetes mellitus? No
Q10 Are you currently taking any prescribed medication we need to be made aware of? If so, what?
No medication
Q11 Are you pregnant or have you given birth in the last 6 weeks? N/A
Q12 Have you recently undergone surgery or are you carrying any injury? No
Q13 Are you aware of any other reasons why you should not participate in physical exercise without medical supervision?
If so, what? No
If you have answered YES to any of Q1 to Q13, we will require you to obtain written consent from your doctor before agreeing
to undertake any form of fitness testing, physical activity, training or exercise with you. We suggest you talk to your doctor by
phone or in person before you begin becoming more physically active and certainly before you undertake any form of formal
fitness assessment. Tell your doctor about this questionnaire and which questions you answered YES to.
You may be able to do any activity you want as long as you begin slowly and build up gradually, or you may need to restrict your
activities to those which are safe for you. Talk with your doctor about the kinds of activity you wish to participate in and follow
his/her advice.
Please state YES or NO
Q14 Is your blood pressure known to be higher than average (over 120/80)? No
Q15 Is your level of cholesterol known to be high? No
Q16 Is there any history of coronary heart disease or coronary artery disease in your parents or siblings before the age of
55? No
On induction recheck - Blood pressure reading, Resting heart rate
If you have answered YES to two or more of Q14 to Q16, for safety reasons we will restrict any programme of exercise to a
moderate intensity unless you obtain written consent from your doctor to exercise at a higher intensity. Moderate intensity is a
level at which you are able to comfortably sustain exercise for up to at least 60 minutes (usually not exceeding 65 of your
maximal heart rate).
