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How do we screen and stratify a client before prescribing exercise, and when must we refer them on?

Investigate pre-exercise screening, risk stratification and informed consent as the duty-of-care steps that precede a safe exercise prescription

A focused HSC Health and Movement Science answer on pre-exercise screening - why we screen, the PAR-Q+ and the AusEP Adult Pre-Exercise Screening Tool, spotting contraindications and risk factors, stratifying clients as low, moderate or high risk, knowing when to refer to a doctor or allied-health professional, and informed consent.

Generated by Claude Opus 4.89 min answerUpdated 2026-06-02

Reviewed by: AI editorial process; not yet individually human-reviewed

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What this sub-topic is asking

NESA wants you to explain why we screen people before prescribing exercise, use the standard screening tools (the PAR-Q+ and the Australian Adult Pre-Exercise Screening Tool) to identify contraindications and risk factors, stratify a client as low, moderate or high risk, decide when to refer them to a medical or allied-health professional, and obtain informed consent - the duty-of-care steps that come BEFORE any program is written.

In plain English

Before a coach or trainer hands you a program, they need to make sure exercise will not hurt you. Screening is the safety questionnaire at the start - a few questions about your heart, your health and your family history.

Think of it like the safety check before a theme-park ride. The attendant asks if you have a heart condition or a bad back (that is screening), looks at who can ride safely and who cannot (that is stratifying you into low, moderate or high risk), and if something looks risky they send you to first aid instead of onto the ride (that is referral). Finally, the sign that says "ride at your own risk, and you can step off any time" is informed consent - you agree to go ahead knowing what is involved.

The golden rule for the exam: screen first, sort the person into low / moderate / high risk, refer anyone with a red flag, and never start until they have understood the risks and agreed. The harder the planned exercise, the stricter the check - a gentle walk needs little, an all-out sprint session needs a lot.

The answer

Screening is the first duty-of-care step in Focus Area 2: you cannot safely prescribe training until you know who you are training. The sequence is always the same - screen, stratify, refer if needed, consent - and the intended exercise intensity sets how strict each step must be.

Why we screen

Exercise is overwhelmingly beneficial, but for a small number of people a sudden bout of vigorous activity carries real risk - most seriously a cardiac event in someone with undiagnosed disease. Screening exists to find those people before they exercise. It serves four jobs at once:

Safety / duty of care - detect conditions, signs and symptoms that make exercise unsafe.
Program design - match the program to the client's true health status and capacity.
Referral - decide who needs a doctor or allied-health professional first.
Legal evidence - a completed, stored form shows reasonable care was taken.

The screening tools

PAR-Q (Physical Activity Readiness Questionnaire). A short, self-administered "yes/no" questionnaire. A traditional PAR-Q "yes" meant "see a doctor before exercising".
PAR-Q+. The updated, expanded version. It adds structured follow-up questions for anyone who answers "yes", so many people with a stable condition can still begin without needing a doctor's clearance - it screens more precisely rather than just blocking.
Adult Pre-Exercise Screening Tool (APSS / AusEP). The Australian tool, published jointly by the fitness and exercise-science bodies (AUSactive and ESSA). It runs in three stages of increasing detail:
- Stage 1 (mandatory, self-report): looks for known cardiovascular, metabolic or renal disease and any signs or symptoms of these.
- Stage 2 (optional): gathers cardiovascular risk factors and basic measures (e.g. blood pressure, body mass) to refine the picture.
- Stage 3 (professional): detailed assessment by a qualified professional for higher-risk clients.

Contraindications and risk factors

A contraindication is a condition or sign that means a person should not exercise (or not until cleared). Absolute contraindications - such as unstable angina, a recent uncontrolled cardiac event, acute infection with fever or uncontrolled severe hypertension - mean do not start. Relative contraindications mean proceed only with caution, modification or clearance.

Risk factors raise the likelihood of an adverse event without being a condition in themselves. Sort them into:

Modifiable (can be changed): smoking, physical inactivity, high blood pressure, high cholesterol, obesity, poor diet.
Non-modifiable (cannot be changed): age, sex, family history of cardiovascular disease.

Risk stratification

Screening answers sort the client into one of three categories, which set the safe ceiling on intensity:

Low risk - no risk factors, no signs/symptoms, no known disease. May begin light-to-moderate exercise without medical clearance.
Moderate risk - one or more risk factors but no signs/symptoms or known disease. May begin light-to-moderate exercise; needs medical clearance before vigorous exercise.
High risk - a warning sign/symptom or known cardiovascular, metabolic or renal disease. Should not begin until medically assessed and cleared.

The intended intensity shifts the decision: the same moderate-risk client can walk today but needs clearance before sprint intervals. This is why "what do they want to do?" is part of every screening decision.

When to refer

Refer to a medical or allied-health professional (a GP, or an accredited exercise physiologist for clients with chronic or complex conditions) when screening flags:

a known cardiovascular, metabolic or renal disease;
a warning sign/symptom (chest pain/discomfort, unusual breathlessness, dizziness/fainting, palpitations);
an absolute contraindication;
high-risk status before vigorous exercise.

Referral keeps the professional inside their scope of practice: prescribe only within the written clearance returned, and re-screen whenever the client's health status changes.

Worked exam answers

Worked example 1 - short answer (3 marks)

Question. A new gym member answers "yes" to "has your doctor ever said you have a heart condition?" on a PAR-Q. Outline the correct actions for the trainer.

Model answer. The "yes" is a screening flag for known cardiovascular disease, so the trainer should not commence a program at this point. They should refer the member to a medical professional (their GP, or an accredited exercise physiologist) for assessment and written clearance, and prescribe only within any limits that clearance specifies. The form should be recorded and the member re-screened if their condition changes. Using the PAR-Q+ follow-up questions may clarify whether the condition is stable enough to begin light activity, but referral remains the safe default for an unexplained cardiac flag.

Marker's note: full marks need "do not proceed", "refer to a named professional for clearance", and "act within / record the clearance". "Tell them to be careful" or starting a light program without clearance scores nothing for a flagged cardiac condition.

Worked example 2 - distinguish (3 marks)

Question. Distinguish a contraindication from a risk factor, and classify "uncontrolled high blood pressure today" and "a parent who had a heart attack" as one of each.

Model answer. A contraindication is a condition or sign that means a person should NOT exercise (or not until cleared) because exercise would be unsafe; a risk factor only raises the LIKELIHOOD of a future adverse event without itself stopping exercise. Uncontrolled high blood pressure today is a (relative-to-absolute) contraindication - it should be controlled or cleared before exercise. A parent who had a heart attack is a non-modifiable risk factor (family history) - it raises risk and informs stratification but is not, by itself, a reason to stop.

Marker's note: markers want the contraindication-versus-risk-factor distinction stated explicitly, then each example placed on the correct side. Swapping the two caps the mark.

Common traps

Confusing a risk factor with a contraindication: A risk factor (e.g. family history) raises risk; a contraindication (e.g. unstable angina) stops exercise. They are not the same, and a "distinguish" question is testing exactly this line.
Forgetting intensity: Screening is not only about the person - it is about what they intend to do. A moderate-risk client can usually begin light-to-moderate exercise but needs clearance before vigorous exercise. Answers that ignore intended intensity lose marks.
Treating screening as a one-off: Health status changes. Re-screen when a client reports new symptoms, a new diagnosis, pregnancy or a long lay-off. Storing the form is part of duty of care, not paperwork for its own sake.
Confusing informed consent with screening: Screening assesses risk; informed consent is the client's voluntary agreement AFTER risks are disclosed. You need both. For a minor (under 18), a parent or guardian must consent.
Acting outside scope: An exercise professional who keeps coaching a flagged high-risk client without referral has breached duty of care, even if nothing goes wrong.

Practice questions

Original practice questions graded from foundation to exam level, each with a full worked solution. Try them before revealing the solution.

foundation3 marksOutline three reasons an exercise professional screens a new client before prescribing any exercise.

Show worked solution →

Any three, clearly stated as reasons:

Safety / duty of care - to detect conditions or signs that make exercise risky, reducing the chance of an adverse event (e.g. a cardiac event).
To identify contraindications that mean the person should not start, or not until medically cleared.
To decide whether referral is needed to a doctor or allied-health professional before proceeding.
To design an appropriate, individualised program matched to the client's risk, health status and goals.
Legal / record-keeping - documented screening is evidence the professional met their duty of care.

Marking criteria: 1 mark for each of three correct, distinct reasons. A bare "to keep them safe" stated three different ways earns 1 mark only - the reasons must be distinct.

foundation4 marksDefine a contraindication. Distinguish a modifiable from a non-modifiable risk factor, giving one example of each.

Show worked solution →

Contraindication = a specific condition or sign that means a person should not exercise (or not until cleared) because exercise would be unsafe - for example unstable angina or an acute infection with fever.

Modifiable risk factor = one the person can change through behaviour or treatment, e.g. smoking, physical inactivity, high blood pressure, high cholesterol or obesity.

Non-modifiable risk factor = one that cannot be changed, e.g. age, sex or family history of cardiovascular disease.

Marking criteria: 1 mark for a correct definition of contraindication; 1 mark for correctly defining modifiable vs non-modifiable; 1 mark for a valid modifiable example; 1 mark for a valid non-modifiable example.

core4 marksA gym uses a short screening form. Of 200 new members in one month, the illustrative ExamExplained dataset records: 150 answer NO to every question (no risk factors flagged); 38 flag one or two modifiable risk factors but no signs or known disease; 12 flag a warning sign or known cardiovascular/metabolic/renal disease. (a) Using low/moderate/high categories, classify each group and state how many fall in each. (b) Describe what action the gym should take for the 12 members in the highest group.

Show worked solution →

(a) Classification (illustrative ExamExplained dataset).

Low risk - 150 members: no risk factors, signs or known disease, so they may begin light-to-moderate exercise without medical clearance.
Moderate risk - 38 members: one or more risk factors but no signs/symptoms or known disease; they may start light-to-moderate exercise, and would seek medical clearance before vigorous exercise.
High risk - 12 members: a warning sign/symptom or known cardiovascular, metabolic or renal disease; they should not begin until cleared.

(b) Action for the 12 high-risk members. Do not commence (or pause) the exercise program; refer them to a medical or allied-health professional (GP, or an accredited exercise physiologist) for assessment and clearance. Obtain written clearance specifying any limits, then prescribe within those limits and re-screen if status changes. Record the form and the referral.

Marking criteria: (a) 1 mark for correctly mapping each group to low/moderate/high, 1 mark for the three counts (150 / 38 / 12). (b) 1 mark for "do not proceed / refer", 1 mark for naming the professional and acting within written clearance. Stating the numbers without the correct category, or "tell them to see a doctor" with no clearance/record step, caps the marks.

core5 marksExplain how the intended intensity of exercise, and the presence of warning signs, change a screening decision. Use a moderate-risk and a high-risk client to illustrate.

Show worked solution →

Screening decisions depend on BOTH the client's risk category AND what they intend to do.

Intensity raises the bar. Light-to-moderate exercise (e.g. walking) carries low absolute risk, so many clients can begin without clearance. Vigorous exercise sharply raises cardiac demand, so the threshold for requiring medical clearance is lower.
Moderate-risk client (one or more risk factors, no signs, no known disease): may begin LIGHT-TO-MODERATE exercise straight away; should obtain medical clearance BEFORE progressing to VIGOROUS exercise.
Warning signs override the category. Chest pain/discomfort, unusual breathlessness, dizziness/fainting or palpitations are red flags. If present, screening stops and the client is referred regardless of intended intensity.
High-risk client (a warning sign or known cardiovascular/metabolic/renal disease): should not begin at any intensity until medically assessed and cleared; once cleared, exercise is prescribed within the stated limits, often with supervision.

Marking criteria: 1 mark for linking intensity to the clearance threshold; 1 mark for the moderate-risk light-vs-vigorous distinction; 1 mark for identifying warning signs as override red flags; 1 mark for the high-risk "do not start until cleared" rule; 1 mark for an explicit, correct contrast between the two clients. Describing risk categories without linking them to intensity/signs caps at 3.

core4 marksJustify the use of informed consent before an exercise program, including what must be disclosed.

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Justification. Informed consent protects the CLIENT (they choose to participate knowing the risks and benefits) and the PROFESSIONAL (it evidences that risks were disclosed, supporting duty of care). It makes participation voluntary and lawful, especially where some risk remains after screening.

What must be disclosed (for consent to be "informed"):

the purpose and procedures of the program/testing;
the risks and potential discomforts;
the expected benefits;
the right to ask questions, and to withdraw at any time without penalty.

Consent must be voluntary and given by someone competent to consent; for a minor (under 18) a parent or guardian must consent on their behalf.

Marking criteria: 1 mark for a clear justification (protects client AND professional / duty of care); up to 2 marks for the disclosed elements (purpose, risks, benefits, right to withdraw); 1 mark for voluntariness or the minor/guardian point. A definition with no justification caps at 2.

exam10 marksAnalyse how pre-exercise screening, risk stratification, referral and informed consent work together to allow an exercise professional to meet their duty of care when prescribing exercise to a new adult client.

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This is a 10-mark extended response. Markers reward a sustained analysis that links each step to the next and to the duty-of-care outcome, not four separate definitions.

Band 6 PLAN.

Thesis: screening, stratification, referral and informed consent form a single risk-management sequence - each step feeds the next - so that any foreseeable harm is identified and managed before a single exercise is prescribed, which is exactly what duty of care requires.
Argument line 1 - Screening detects: a structured tool (PAR-Q+ or the AusEP Adult Pre-Exercise Screening Tool, Stage 1) systematically asks for known cardiovascular/metabolic/renal disease, signs and symptoms, and risk factors - so risk is found deliberately, not by chance.
Argument line 2 - Stratification classifies: the answers sort the client into low, moderate or high risk, which sets the safe ceiling on intensity (e.g. moderate-risk clients clear medically before vigorous exercise; high-risk clients do not start until cleared).
Argument line 3 - Referral manages what the professional cannot: where a contraindication, warning sign or known disease is flagged, the client is referred to a GP or accredited exercise physiologist, and exercise is then prescribed within the written clearance - the professional acts within scope of practice.
Argument line 4 - Informed consent legitimises the residual risk: once risk is understood and managed, the client voluntarily consents after disclosure of purpose, risks, benefits and the right to withdraw (guardian consent for minors).
Synthesis: judge that the four steps are interdependent - skipping stratification makes referral arbitrary; skipping consent leaves residual risk unauthorised - so duty of care is met by the SEQUENCE, not any single form.

Model paragraph (referral line). Referral is the step that keeps the professional inside their scope of practice. When Stage 1 of the Adult Pre-Exercise Screening Tool flags a known cardiac condition or a warning sign such as chest discomfort on light exertion, the appropriate action is not to modify the program independently but to pause and refer the client to a GP or an accredited exercise physiologist. The clearance that returns is not a formality: it specifies the limits - permitted intensities, contraindicated movements, supervision needs - inside which the program may safely run. By prescribing only within that clearance, the professional both manages a risk they are not qualified to assess alone and creates a documented record that reasonable care was taken, which is the legal substance of duty of care.

Marker's note: top-band answers (1) name real tools (PAR-Q+, AusEP/APSS) and the three risk categories, (2) LINK the steps as a sequence rather than defining them in isolation, (3) tie intended intensity to the clearance threshold, and (4) keep answering the verb - ANALYSE means show how the parts interrelate to produce the duty-of-care outcome. Noting that consent must be voluntary and that minors need guardian consent signals precision.