HEALTH SCREENING FORM

Our Casa Loma gymnasium is OPEN for the Winter Semester

Please complete the Health Screening Questionnaire PRIOR to your scheduled activity. This only needs to be filled out once a semester.

1. You must fill out the full registration form.
2. Please bring indoor shoes and your own water bottle.
3. You must be on time for your scheduled activities. If you're late, you will not be permitted to participate.

Email address *

First name *

Last name *

Cell Phone Number *

GBC Student Number *

HEALTH SECTION

The health benefits of regular physical activity are clear, more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.

1. Has you doctor ever said that you have a heart condition or high blood pressure? *

Yes No

2. Do you feel pain in your chest at rest, during your daily activities of living or when you do physical activity? *

Yes No

3. Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? *

Please answer NO if your dizziness was associated with over-breathing (Including during Vigorous exercise).

Yes No

4. Have you ever been diagnosed with another chronic medical condition (Other than heart disease or high blood pressure)? *

Yes No

IF YOU SELECTED YES, PLEASE LIST CONDITION(S) AND MEDICATES BELOW.

5. Are you currently taking prescribed medications for a chronic medical condition? *

Yes No

IF YOU SELECTED YES, PLEASE LIST CONDITION(S) AND MEDICATES BELOW.

6. Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? *

Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.

Yes No

Please list condition(s) here:

If you answered NO to all the questions above, you are cleared for physical activity. You do not need to complete the next section and can scroll to the bottom to complete the registration.

If you answered YES to one or more of the questions about your medical condition please complete the following section.

2021 Par-Q+ Follow-Up Questions About Your Medical Condition(S)

1. Do you have arthritis, osteoporosis, or back problems?

If NO go to question 2

Yes No

1A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments.

Yes No

1B. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Yes No

1C.Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

Yes No

2. Do you currently have Cancer of any kind?

If NO go to question 3

Yes No

2A. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

Yes No

2B. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?

Yes No

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

If NO go to question 4

Yes No

3A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments.

Yes No

3B. Do you have an irregular heart beat that requires medical management? (eg: atrial fibrillation, premature ventricular contraction)

Yes No

3C.Do you have chronic heart failure?

Yes No

3D. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

Yes No

4. Do you currently have High Blood Pressure?

If NO go to question 5

Yes No

4A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments.

Yes No

4B. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?

Answer YES if you do not know your resting blood pressure.

Yes No

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes?

If NO go to question 6

Yes No

5A. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician prescribed therapies?

Yes No

5B. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

Yes No

5C. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

Yes No

5D. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

Yes No

5E. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

Yes No

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer's, Dementia ,Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome.

If NO go to question 7

Yes No

6A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments

Yes No

6B. Do you have Down Syndrome AND back problems affecting nerves or muscles?

Yes No

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure.

If NO go to question 8

Yes No

7A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments

Yes No

7B. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

Yes No

7C. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

Yes No

7D. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

Yes No

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia.

If NO go to question 9

Yes No

8A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments

Yes No

8B. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

Yes No

8C. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

Yes No

9. Have you had a Stroke? This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event

If NO go to question 10

Yes No

9A. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Answer NO if you are not currently taking medications or other treatments

Yes No

9B. Do you have any impairment in walking or mobility?

Yes No

9C. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

Yes No

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

Yes No

10A. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

Yes No

10B. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

Yes No

10C. Do you currently live with two or more medical conditions?

Yes No

If you answered NO to all the follow up questions, you are cleared for physical activity and can scroll to the bottom to complete the registration.

If you answered YES to one or more of the follow-up questions about your medical condition please DO NOT book a Gym or Fitness Centre spot. In order to use the GBC Athletic Facilities, you are required to take this form to your doctor and return to GBC Athletics clearing you to engage in physical activity. Please complete the following section: http://eparmedx.com/wp-content/uploads/2013/03/ePARmedX-Physician-Clearance-Form-2014.pdf

Participants Signature (Type Name) *

Participants under the age of 18

I certify that by participating event(s) hosted by GBC Recreation, I will abide by the George Brown College Code of Student Behaviour and Community Standards.

If you have any questions, please contact Tammy Nopuente.

Signature of Parent/Guardian (Type Name):

Date *

* required field

HEALTH SCREENING FORM

Our Casa Loma gymnasium is OPEN for the Winter Semester

HEALTH SECTION

2021 Par-Q+ Follow-Up Questions About Your Medical Condition(S)

I certify that by participating event(s) hosted by GBC Recreation, I will abide by the George Brown College Code of Student Behaviour and Community Standards. If you have any questions, please contact Tammy Nopuente.

I certify that by participating event(s) hosted by GBC Recreation, I will abide by the George Brown College Code of Student Behaviour and Community Standards.

If you have any questions, please contact Tammy Nopuente.