USI
PHYSICAL EDUCATION DEPARTMENT
Physical Fitness Testing
Health History
Questionnaire
Date: _______________
General and Demographic
Information:
Name: ____________________________________ Current
Address:
_________________________________________________
Phone:
__________________________________________________ Email Address: ____________________________________ Primary Secondary
Gender: Male _________ Female ________ Ethnicity: African-American Asian American Hispanic (Circle One) Native American White Other
___________
Academic Year: First Semester Freshmen First Semester Sophomore First Semester Junior First Semester Senior
(Circle
One)
Second Semester Freshmen Second
Semester Sophomore Second Semester
Junior
______________________________________________________________________________________________________________
To help the PE
department and determine if you should consult your doctor before starting to
exercise, please read the following questions carefully and answer each
honestly. All information will be kept
confidential. Please check YES or NO:
YES NO
O
O 1. Has a physician ever
told you or do you have high blood pressure?
O
O 2. Has a physician ever
told you or do you have a high cholesterol level?
O O 3.
Do you smoke?
O O 4.
Are you obese (more than 30% overweight)?
O O 5.
Has anyone in your immediate family (parents/brothers/sisters) had a heart
attack, stroke, or cardiovascular disease before age 55?
O O 6.
Are you a male over 44 years of age?
O O 7. Are you a female over 54 years of age?
O O 8.
Do you have diabetes?
O
O 9. Do you have a heart condition? If yes please explain:
O O 10. Have you had a stroke?
O O 11.
Do you have epilepsy?
O O 12.
Are you pregnant?
O O 13. Do you have emphysema?
O O 14. Do you feel pain in your chest when you
engage in physical activity?
O O 15. Do you have chronic bronchitis?
O O 16.
Have you had chest pain when you were not doing physical activity in the past month?
O O 17.
Do you ever lose consciousness or control of your balance due to chronic
dizziness?
O O 18.
Are you currently being treated for a bone or joint problem that restricts you
from engaging in physical activity?
O O 19.
Are you taking any medications or other drugs that might alter your response to
physical activity or exercise?
If yes please explain:
O O 20.
Is there a good reason not mentioned above why you should not be physically
active, even if you wanted to?
If yes please explain:
O O 21.
Have you recently had surgery or have special limitations? What are they? __________________________________
IF
YOU ANSWERED…
YES TO ONE OR MORE
QUESTIONS
Talk to your doctor by phone BEFORE you
start becoming much more physically active or BEFORE you have a fitness
appraisal. Testing. Tell your doctor about this health history
questionnaire and which questions you answered YES.
· You may be able to do any physical activity
you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for
you. Talk with your doctor about the kinds
of activities you wish to participate in and follow
his/her advice.
· Find out which community programs are safe
and helpful for you.
NO TO ALL QUESTIONS
If you answered NO honestly to all health
history questions, you can be reasonably sure that you can:
· Start becoming much more physically active -
begin slowly and build up gradually.
This is the safest and easiest way to go.
· Take part in a fitness appraisal - this is an
excellent way to determine your basic fitness so that you can plan the best way
for you to live actively.
LIABILITY
I understand that any
physical activity I undertake may create physical stress and subsequent harmful
effects. I recognize that the use of the
equipment in the physical fitness testing entails some risk of accidental
injury to myself and to others and I agree that I will use such equipment and
facilities with due care. I agree that it is solely my responsibility and not
the responsibility of the University of Southern Indiana Physical Education
Department to require me to consult with a physician prior to commencing in the
Physical Fitness Testing, to remain under medical supervision if that is
indicated, and to seek medical assistance in the event of an injury.
Name__________________________________ Signature_____________________ Date
_________________
INFORMED
CONSENT FOR RESEARCH PURPOSES
Your participation in
allowing the
Your name will remain
confidential. Your personal information
will not be made public. By signing
below, you are allowing the
Name__________________________________ Signature_____________________ Date
_________________
ACSM (1997). ACSM’s Health/Fitness Standards and
Guidelines:
FOR
INSTRUCTOR USE:
Risk areas discussed:
Modifications made by instructor due to
risk factors:
Instructor Signature Date Student
Signature Date