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printer-friendly version| AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire Asses your health needs by marking all true statements. History 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 Symtoms __ 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 |
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