Health Screening Clinic Pre-Assessment Questionnaire | Health Screening Clinic | Kinesiology & Sport Management

If you see this don't fill out this input box.

*Name

*Cell or Work Phone

*Email Address

*Sex

*Age (years)

*Weight (lbs)

Height

*feet

*inches

Emergency Contact

*Name

*Phone

Signs and Symptoms

Please check all statements that apply to you.

chest pain at rest, during your daily activities, or with exercise

difficulty breathing at rest

difficulty breathing while lying flat

difficulty breathing that wakes you up at night

dizziness, lightheadedness, blackouts, or fainting at rest or with activity

ankle or foot swelling after sitting for 30 minutes or more

unpleasant feeling of a forceful, rapid, or irregular heart rate

burning or cramping sensations in buttocks, thigh, or calf when walking a short distance

None of the above

Health Status

Exercise Status

*Do you regularly engage in aerobic exercise (i.e., jogging, cycling, walking, etc.)?

Yes

If yes, how long have you engaged in this form of exercise?

years

months

If yes, how many hours per week do you spend for this type of exercise?

hours

*Do you participate in resistance training (free weights, machine weights, bands)?

Yes

If yes, how long have you engaged in this form of exercise?

years

months

If yes, how many hours per week do you spend for this type of exercise?

hours

*Do you regularly play recreational sports (i.e., basketball, racquetball, volleyball, etc.)?

Yes

If yes, how long have you engaged in this form of exercise?

years

months

If yes, how many hours per week do you spend for this type of exercise?

hours

Physical Examination History

*Approximate date of your last physical examination

Physical problems noted at that time

*Has a physician ever stated you should limit your exercise or activity?

Yes

If yes, what limitations were recommended?

Current Medication

Please list each medication name and the condition being managed on a separate line.

Be sure to include both the MEDICATION NAME and the CONDITION. If NONE, please write N/A.