Child's Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Over the past seven days, on how many days was your child physically active for a total of 60 minutes or more per day?

1

2

3

4

5

6

7

Does your child have, or previously had

Dizziness or fainting spells with physical activity

A heart condition

Uncontrolled epilepsy

Diabetes

An asthma attack requiring immediate medical attention at any time over the last 12 months?

Anaphylactic reactions?

Cleared to exercise by a medical health professional?

Yes

No

Not applicable

Are they currently on prescription medication?

Yes

No

Have they been hospitalised recently?

Yes

No

Do they have any injuries or restrictions?

Yes

No

Any other conditions requiring exercise modification?

Yes

No

Date

MM

DD

YYYY