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.
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
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