Med-Fit Tech Assistant
Medical-Fitness Assessment - Learning Module #5
Pre-Participation Screening
Part B
Part B: Screening Questionnaire
Question 1: Current SYMPTOMS - Have you been experiencing any...?
YES - If the individual has been experiencing any symptom listed above, STOP: Medical Clearance is required.
NO - If the individual has NOT been experiencing any symptom listed above, continue to Question 2.
Question 1: Current SYMPTOMS - Have you been experiencing any...?
- Chest discomfort (angina) with (stable) or without (unstable) exertion
- Unreasonable breathlessness
- Dizziness, fainting, or blackouts
- Ankle swelling (edema)
- Forceful, rapid, or irregular heart beats (palpitations)
- Burning or cramping in your calves when walking (intermittent claudication)
YES - If the individual has been experiencing any symptom listed above, STOP: Medical Clearance is required.
NO - If the individual has NOT been experiencing any symptom listed above, continue to Question 2.
Question 2: MEDICAL HISTORY - Have you had...?
NO - If the individual does not have a medical history of any condition listed above, you may STOP, Medical Clearance is NOT required.
YES - If the individual has a medical history of any condition listed above, continue to Question 3.
- Heart attack
- Cardiac catheterization or angioplasty
- Heart transplant
- Pacemaker, defibrillator, or dysrhythmia
- Heart valve disease
- Heart failure
- Congenital heart condition
- End-stage Renal Disease
NO - If the individual does not have a medical history of any condition listed above, you may STOP, Medical Clearance is NOT required.
YES - If the individual has a medical history of any condition listed above, continue to Question 3.
Question 3: EXERCISE - Have you been exercising regularly?
Have the individual describe his/her pattern of exercise and determine their answer as Yes or No:
Yes > 90 minutes of moderate-intensity physical activity per week for the past 3 months
No < 90 minutes of moderate-intensity physical activity per week for the past 3 months
YES - If the individual has been exercising regularly, Medical Clearance is NOT required.
NO - If the individual has not been exercising regularly, but has a history of a heart condition, Medical Clearance is required.
Have the individual describe his/her pattern of exercise and determine their answer as Yes or No:
Yes > 90 minutes of moderate-intensity physical activity per week for the past 3 months
- Example: 30 minutes of brisk walking/jogging at least 3 days per week for the past 3 months
No < 90 minutes of moderate-intensity physical activity per week for the past 3 months
- Example: A 60 minute walk every Sunday for the past 6 months
YES - If the individual has been exercising regularly, Medical Clearance is NOT required.
NO - If the individual has not been exercising regularly, but has a history of a heart condition, Medical Clearance is required.