Preparticipation Screening / Assessment

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