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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