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Human Performance Laboratory Health History Screening

  • AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire

    Instructions: Assess your health needs by marking all true statements. Please explain any checked boxes in space provided on the next page.  Submit to the DiSepio Institute for Rural Health & Wellness Human Performance Laboratory.  HIPPA guidelines are followed. Refer to Informed Consent to be signed on the day of your test. If applicable, please explain any checked items in the box provided on page 2.

    Name: 
    History:
    Check the following you currently have or have had in the past:

     
           
    Symptoms:
           
    Cardiovascular Risk Factors:

     
         
    Explanation of checked boxes:  Please include specific diagnosis and dates where applicable.

       
    Additional Comments:

    By signing this form I agree that all of the above information is true and accurate. 
    Signature: 
    An electronic signature is just as binding legally as a conventional, handwritten signature.  By typing your name in the Signature box you will transmit to us your consent to use your typed name as your electronic signature, but only for the designations you've just entered.

    Balady et al. (1998). AHA/ACSM Joint Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities. Medicine & Science in Sports & Exercise, 30(6). (Also in: ACSM’s Guidelines for Exercise Testing and Prescription, 9th Edition, 2014. Lippincott Williams and Wilkins)