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Health Screening Clinic
Health Screening Clinic Pre-Assessment Questionnaire
Pre-Assessment Questionnaire
If you see this don't fill out this input box.
*
Name
*
Cell or Work Phone
*
Email Address
*
Sex
Please Select
Male
Female
Intersex
Prefer not to answer
*
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
Please check all statements that apply to you.
High Blood Pressure (hypertension)
Heart Disease, Heart Valve Disease, or Coronary Artery Disease
Peripheral Circulatory Disorder, Peripheral Vascular Disease, or Peripheral Arterial Disease
Heart surgery (bypass surgery, heart cath, angioplasty)
Heart Murmur
Irregular heart beat (arrhythmia)
Pacemaker or Implantable Defibrillator (ICD)
Joint, soft tissue, bone, tendon, ligament, or back problem that would worsen with exercise
Diabetes
Kidney (renal) disease
Allergic reactions to rubbing alcohol
None of the above
Exercise Status
*
Do you regularly engage in aerobic exercise (i.e., jogging, cycling, walking, etc.)?
Yes
No
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
No
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
No
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
No
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.
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Health Screening Clinic
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Address
Texas Tech University, Box 43011, 2500 Broadway, Lubbock, TX 79409-3011
Phone
806.834.0160
Email
ksm.healthclinic@ttu.edu
Health Screening Clinic
Assessment Descriptions
Links
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OP 70.48 Wellness Program Leave
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Wellness Program Leave
Blue Cross Blue Shield
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ERS Health & Wellness Incentives
Location
Health information Links
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More
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What is High Blood Pressure
How to Measure Blood Presure
High Blood Pressure
Heart Disease
Type 2 Diabetes
Overweight and Obesity
Women and Heart Disease
Weight Loss
Lab Tests
Health Screening Clinic
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What is Cholesterol
A1C Diabetic testing
Exercise Training
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General Aerobic Training Information
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Tips for Monitoring Aerobic Execise Intensity
High-Intensity Interval Training: For Fitness, For Health or Both?
General Resistance Training Information
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Resistance Training for Health
Effects of Resistance Training on Lean Weight, Fat Weight, and Metabolism
General Information on Stretching and Muscle Recovery
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A Road Map to Effective Muscle Recovery
Upper Body Exercises
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Chin-up Technique
Dumbbell Bench Press
Pull-up
Lower Body Exercises
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Bodyweight Squat
Forward Lunge
Core Exercises
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Plank
Russian Twist
Side Bridge
Exercises for Warm-up, Cool-down, and Stretching
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Cat-Cow Stretch
Dynamic Hip Rotation
Soldier Walk Technique
Additional Resources
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