Below is the Preparticipation Screening Questionaire.
Answer them truthfully and it may save your life.
Run safe always.
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AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire
Assess your health needs by marking all true statements.
History
If you marked any of the statements in this section,
consult your physician or other appropriate healthcare
provider before engaging in exercise. You may need
to use a facility with a medically qualified staff.
You have had:
___ A heart attack
___ Heart surgery
___ Cardiac catheterization
___ Coronary angioplasty (PTCA)
___ Pacemaker/implantable cardiac defibrillator/rhythm disturbance
___ Heart valve disease
Other health issues
___ Heart failure
___ You have diabetes
___ Heart transplantation
___ You have or asthma other lung disease.
___ Congenital heart disease
___ You have burning or cramping in your lower legs
when walking short distances.
Symptoms
___ You have musculoskeletal problems that limit your
___ You experience chest discomfort with exertion.
physical activity.
___ You experience unreasonable breathlessness.
___ You have concerns about the safety of exercise.
___ You experience dizziness, fainting, blackouts.
___ You take prescription medication(s).
___ You take heart medications.
___ You are pregnant.
_________________________________________ ____________________________________________
Cardiovascular risk factors
___ You are a man older than 45 years.
___ You are a woman older than 55 years, you
have had a hysterectomy, or you are postmenopausal.
___ You smoke, or quite within the previous 6 mo.
If you marked two or more of the statements in this
section, you should consult your physician or other
appropriate healthcare provider before engaging in
exercise. You might benefit by using a facility with a
professionally qualified exercise staff to guide
your exercise program.
___ Your BP is greater than 140/90.
___ You don't know your BP.
___ You take BP medication.
___ Your blood cholesterol level is >200 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 (i.e., you get less than 30 min. of physical activity on at least 3 days per week).
___ You are more than 20 pounds overweight.
_________________________________________ ____________________________________________
You should be able to exercise safely without consulting
your physician or other healthcare provider in a self-
guided program or almost any facility that meets your
exercise program needs.
___ None of the above is true.
_________________________________________ ____________________________________________
Balady et al. (1998). AHA/ACSM Joint Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness
Facilities. Medicine & Science in Sports & Exercise, 30(6). (Also in: ACSM’s Guidelines for Exercise Testing and Prescription, 7th Edition, 2005.
Lippincott Williams and Wilkins http://www.lww.com )
www.acsm-msse.org/pt/pt-core/template-journal/msse/media/0698c.htm
