This form is intended to obtain relevant information about your health that will Diabetes. Do you have diabetes? Yes No. Family History …
Health Screen Form
3 or more
Name: _____________________________________________ Date:
_________________________
This form is intended to obtain relevant information about your health that
will assist in helping you with your program Please answer all questions
to the best of your knowledge
1 Blood Pressure
Do you have high blood pressure?
Yes No
Are you on medication for high blood pressure? Yes
No
2 Smoking
Do you smoke? Yes No
Are you a former smoker? Yes No
If yes, please give the date you quit _________
3 Diabetes
Do you have diabetes? Yes No
4 Family History
Have any of your blood relatives had heart disease, heart surgery,
or angina?
Yes No Unsure
5 Orthopedic Problems
Do you have any serious
orthopedic problems that would prevent you
from exercising? Issues with joints, muscles, ligaments, tendons,
nerves and skin
Yes No If yes, explain
________________________________________________________
6 Other Problems
Do you have any reason to believe you should not exercise?
Yes No If yes, explain
________________________________________________________
7 Physical Exam
When was your last physical exam? ___________________________
8 Exercise History
_________ Sedentary Little or no exercise weekly
_________ Moderately Active Exercise 1-3 times a week
_________ Active Exercise 4-5 times a week
_________ Athletic Exercise 6 or more times a week
9 Emergency Contact
Name ______________________ Telephone____________________
Physical Activity
Readiness Questionnaire
1 or more
Name: ________________________________ Date:
_________________________
This is a simple screening tool used to identify individuals who probably
should not be tested in a field setting without physician clearance The
PAR-Q was developed in Canada and is used throughout North America It was
revised in 1992, and the revised version appears below
Yes No
_______ ________ 1 Has your doctor
ever said that you have a heart
condition and recommended only
medically approved physical
activity?
________ ________ 2 Do you have a chest pain
brought on by physical activity?
________ ________ 3 Have you developed chest
pain at rest in the past month?
________ ________ 4 Do you lose
consciousness or lose your balance
as a result of dizziness?
________ ________
5 Do you have a bone or
joint problem that could be
aggravated by the proposed physical
activity?
________ ________ 6 Is your doctor currently
prescribing medication for your
blood pressure or heart condition?
________ ________ 7 Are you aware, through
your own experience or a doctors
advice, of any other reason against
your exercising without medical
approval?
Source:pedsql.org
