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 cardiac catherization
 Yes  No coronary angioplasty (PTCA)
 Yes  No pacemaker/implantable cardiac defib/rhythm disturbance
 Yes  No heart failure
 Yes  No heart transplantation
 Yes  No congenital heart disease
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/m 2
 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.
Date:________________________ Name:_______________________________________________
Signature:_____________________________________________
PAC Use Only
Total number of positive cardiovascular risk factors
PAC initials/date:
______ 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% VO
2
R; 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% VO
2
R; > 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 , 9 th 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

Therabands

Calisthenics (push-ups, pull-ups, etc.)

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

Elliptical

Swimming

Handball, racquet ball, squash

Stationary cycling

Basketball

Bicycling


Spinning
Aerobic dance/zumba

Stairmaster

Resistance Training

Yoga/Pilates

Free weights

Other (Specify)_____________________________________

Stretching

Machines
7.
What are YOUR physical activity goals?

Improve Health

General Fitness

Lose weight

Build Muscle Mass

Aerobic Fitness

Tone

Strengthen Core

Improve Balance


Improve Flexibility
Improve fitness knowledge


Other (Specify)_______________________________________________
Improve Strength
8.
What are YOUR greatest obstacles to regular exercise?

Time

Motivation

Money

Enjoyment

Pain

Lack of knowledge

Other (Specify)________________________________________________