Name:_____________________________ PeopleSoft #:________________
Date:__________
1
UConn Student Health Services Activity Preparticipation Screening Questionnaire
Answer the following as honestly as possible:
Assess your Health Status by marking all true statements:
History: You have had:
Yes No
a heart attack
Yes No
heart valve disease
Yes No
heart surgery
Yes No
heart failure
Yes No
cardiac catherization
Yes No
heart transplantation
Yes No
coronary angioplasty (PTCA)
Yes No
congenital heart disease
Yes No
pacemaker/implantable cardiac defib/rhythm disturbance
Symptoms:
Yes No
You experience chest discomfort with exertion
Yes No
You experience unreasonable breathlessness
Yes No
You experience dizziness, fainting, or blackouts
Yes No
You experience ankle swelling
Yes No
You experience unpleasant awareness of a forceful or rapid heart rate
Yes No
You take heart medications
Other health issues:
Yes No
You have diabetes
Yes No
You have asthma or lung disease
Yes No
You have burning or cramping sensation in your lower legs when walking short distances
Yes No
You have musculoskeletal problems that limit your physical activity
Yes No
You have concerns about the safety of exercise
Yes No
You take prescription medications
Yes No
You are pregnant
Comments:________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name:_____________________________ PeopleSoft #:________________
Date:__________
2
Cardiovascular risk factors
Yes No
You are a man >45 years
Yes No
You are a woman > 55 years
Yes No
You smoke or quite smoking within the previous 6 months
Yes No
Your blood pressure is > 140/90 mmHg OR You do not know your blood pressure OR You take blood
pressure medication
Yes No
Your blood cholesterol level is > 200 mg/dL (or LDL is > 130 mg/dL or HDL blood cholesterol is < 40
mg/dL) OR You do not know your cholesterol level
Yes No
You have a close blood relative who died suddenly before the age of 50
Yes No
You are physically inactive (i.e. you get < 30 min of moderate intensity physical activity on at least 3 days
of week for past 3 months)[exercise at 40 – 60 % of your maximal intensity]
Yes No
You have a body mass index > 30 kg/m2
Yes No
You have prediabetes (fasting blood glucose > 100 mg/dL on two different occasions) OR You do not
know if you have prediabetes
Yes No
Your HDL > 60 mg/dL (Subtract one risk factor)
Yes No
Have you ever had an injury or pain that has interfered with your ability to exercise? Explain.
__________________________________________________________________________________________________
_________________________________________________________________________________________________
I have read, understood and completed this questionnaire as honestly as possible. Any questions I had were answered
to my full satisfaction.
Name:_______________________________________________
Date:________________________
Signature:_____________________________________________
PAC Use Only
PAC initials/date:
______Total number of positive cardiovascular risk factors
______ 0 - 1 indicates Low Risk: client can begin moderate or vigorous intensity exercise without consulting
physician or other appropriate health care provider
______ > 2 indicates: Moderate Risk
______can begin low to moderate intensity exercise (40 – <60% VO2R; 3 - < 6 METs)
“An intensity that causes noticeable increases in HR and breathing.”
i.e. walking at a moderate or brisk pace of 3 – 4.5 mph (15 – 20 minute/mile), level bicycling,
yoga, weight training
______CANNOT begin vigorous intensity exercise (>60% VO2R; > 6 METs) without medical exam and
clinician approval
“An intensity that causes substantial increases in HR and breathing”
i.e. jogging or running, step aerobics, jumping rope, basketball game, soccer
*Modified from AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire. ACSM’s Guidelines for Exercise Testing
and Prescription , 9th Edition, 2014. Lippincott Williams and Wilkins http://www.lww.com.
Name:_____________________________ PeopleSoft #:________________
Date:__________
3
Physical Activity Questionnaire
1. What physical activities do you engage in on a regular basis?
____________________________________________________________________________________
____________________________________________________________________________________
2. If you walk, run or jog, what is the average number of miles you cover each workout? _________miles
3. If you participate in resistance training, which type of exercises do you perform? (Check all that apply.)
 Free weights
 Machines
 Calisthenics (push-ups, pull-ups, etc.)
 Therabands
 Core training
Please provide specifics (crunches, sit-ups, planks, etc. and repetitions/time performed):
______________________________________________________________________________
______________________________________________________________________________
4. How many minutes, in average, is each or your exercise workouts?____________________minutes
5. How many workouts do you participate in on average each week?____________________ workouts
6. Check those activities that you would prefer in a regular exercise program for yourself:
 Walking, running, jogging
 Handball, racquet ball, squash
 Stationary cycling
 Elliptical
 Basketball
 Spinning
 Swimming
 Bicycling
 Aerobic dance/zumba
 Stairmaster
 Yoga/Pilates
 Stretching
 Resistance Training
 Free weights
 Machines
 Other (Specify)_____________________________________
7. What are YOUR physical activity goals?
 Improve Health
 General Fitness
 Aerobic Fitness
 Lose weight
 Build Muscle Mass
 Tone
 Strengthen Core
 Improve Flexibility
 Improve Strength
 Improve Balance
 Improve fitness knowledge
 Other (Specify)_______________________________________________
8. What are YOUR greatest obstacles to regular exercise?
 Time
 Motivation
 Money
 Enjoyment
 Pain
 Lack of knowledge
 Other (Specify)________________________________________________
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Participation Health Screening Questionnaire