L.I.F.E. Program / K-­‐State CrossFit
Pre-Participation Screening
Name ______________________________________________
Date _____________
Personal Physician __________________________________ Phone # __________________
Reason for last doctor visit? _____________________________________________________
Date of late physical exam: ____________________
Have you ever had any other exercise stress test? o YES o NO
Date and location of test: ________________________________________________________
Have you ever had any cardiovascular tests? o YES o NO
Date and location of test: ________________________________________________________
Please assess your health status by marking all true statements:
FAMILY HISTORY
PERSONAL HISTORY
SYMPTOMS
Have any immediate family
members had a:
Have you ever had:
Have you ever had:
o Heart attack
o Heart surgery
o Coronary stent
o Cardiac catherization
o Congenital heart defect
o Stroke
o Other chronic disease:
_____________________
_____________________
_____________________
o
o
o
o
o
o
o
o
o
o
o
o
High blood pressure
High cholesterol
Diabetes
Any heart problems
Disease of arteries
Thyroid disease
Lung disease
Asthma
Cancer
Kidney disease
Hepatitis
Other: ____________
__________________
__________________
__________________
o
o
o
o
o
o
o
o
o
o
o
o
Chest pain
Shortness of breath
Heart palpitations
Skipped heartbeats
Heart murmur
Intermittent leg pain
Dizziness or fainting
Fatigue- usual
activities
Snoring
Back pain
Orthopedic problems
Other: ____________
__________________
__________________
Have you ever had your cholesterol measured? o YES o NO If yes, value: ___________
Are you taking any prescriptions (include birth control pills) or nonprescription medications?
o YES o NO
For each of your medications, provide the following information:
Dosage – times/day
Time taken
Years on medication
MEDICATION
Reason for taking
Page 1 of 2
HOSPITALIZATIONS: Please list recent hospitalizations. (Women: do not list normal pregnancies.)
Year
Location
Reason
Any other medical problems/concerns not already identified? o YES o NO If so, please list:
____________________________________________________________________________
____________________________________________________________________________
LIFESTYLE HABITS
Do you ever have an uncomfortable shortness of breath during exercise or when doing normal
activities? o YES o NO
Do you ever have chest discomfort during exercise? o YES o NO
Do you currently smoke? o YES o NO If so, what? o Cigarettes o Cigars o Pipe
How long have you smoked? ________________years / months (circle one)
How much per day?
o <½ pack o ½ to 1 pack o 1 to 1½ packs o 1½ to 2 packs o > 2 packs
Have you ever quit smoking? o YES o NO When? ____________________
How many years and how much did you smoke? ____________________
Do you drink any alcoholic beverages? o YES o NO
If yes, how much in 1 week? (indicate below)
Beer ______ (cans)
Wine ______(glasses)
Hard liquor ______ (drinks)
Do you drink any caffeinated beverages? o YES o NO
If yes, how much in 1 week? (indicate below)
Coffee ______ (cups)
Tea (glasses)
Soft drinks ______ (cans)
Are you currently following a weight reduction diet plan? o YES o NO
If so, how long have you been dieting? ______ months
Is the plan prescribed by your doctor? o YES o NO
Have you used weight reduction diets in the past? o YES o NO
If yes, how often and what type? ____________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please list any physical limitations or past/current injuries that affect your exercise
performance:
Head/Neck: __________________________________________________________________
Arms/Wrists/Hands:____________________________________________________________
Abdoment/Trunk/Glutes:_________________________________________________________
Legs/Knees:__________________________________________________________________
Ankles/Feet:__________________________________________________________________
Other: _______________________________________________________________________
Page 2 of 2