|AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire
Asses your health needs by marking all true statements.
You have had:
__ a heart attack
__ heart surgery
__ cardiac catheterization
__ coronary angioplasty (PTCA)
__ pacemaker/implantable cardiac defibrillator/rhythm disturbance
__ heart valve disease
__ heart failure
__ heart transplantation
__ congenital heart disease
__ You experienced chest discomfort with exertion.
__ You experience unreasonable breathlessness.
__ You experience dizziness, fainting, blackouts.
__ You take heart medications.
Other health issues
__ You have musculoskeletal problems.
__ You have concerns about the safety of exercise.
__ You take prescription medication(s).
__ You are pregnant.
If you marked any of the statements in this section, consult your healthcare provider before engaging in exercise. You may need to use a facility with a medically qualified staff.
Cardiovascular Risk Factors
__ You are a man older than 45 years.
__ You are a woman older than 55 years or you have had a hysterectomy or you are post menopausal.
__ You smoke.
__ Your blood pressure is > 140/90.
__ You don't know your blood pressure.
__ You take blood pressure medication.
__ Your blood cholesterol level is > 240 mg/dl.
__ You don't know your cholesterol level.
__ You have a close blood relative who had a heart attack before age 55 (father or brother) or age 65 (mother or sister).
__ You are physically inactive (ie, you get < 30 minutes of physical activity on at least 3 days per week.
__ You are > 20 pounds overweight.
If you marked 2 or more of the statements in this section, consult your healthcare provider before engaging in exercise. You might benefit by using a facility with a professionally qualified exercise staff to guide your exercise program.
__ None of the above is true.
You should be able to exercise safely without consulting your healthcare provider in almost any facility that meets your exercise program needs.
Please print, complete and bring this questionnaire to your physician if you have any further questions.
AHA = represents the American Heart Association
ACSM = American College of Sports Medicine