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Screening for Medical Clearance
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Indicates required field
Participant's Name:
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First
Last
Participant's Phone #:
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Q1: Symptoms:
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Chest pain or discomfort with or without exertion?
Unreasonable breathlessness?
Dizziness, fainting, or blackouts?
Ankle swelling?
Forceful, rapid, or irregular heart beats?
Burning or cramping in calves when walking?
None of the above.
Mark all that apply.
If you marked any of the above symptoms, STOP. The participant must obtain medical clearance before participating in a Fitness Test or any Exercise Program. The participant may need to use a fitness facility that provides medically qualified supervision.
If you marked "None of the above," continue with Questions 2 & 3 below.
Q2: Exercise
Ask a few questions in order to quantify the participant's current amount and intensity of physical activity. Even if the participant doesn't exercise at all, they can usually proceed with the Fitness Tests, depending on their Medical History (Q3).
Have the participant describe their exercise pattern over the past 3 months:
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Calculate the participant's Average Total Minutes of Exercise per Week and indicate the intensity of their exercise:
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Days/week x Minutes/Day = Minutes/Week; Intensity: Low / Moderate / High
Qualification: Has the participant been exercising for at least 30 MINUTES per day at MODERATE INTENSITY on at least 3 DAYS per week over the past 3 MONTHS?
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Yes
No
If you marked "Yes" (and Q1 was "None of the above" = asymptomatic), the Participant does NOT need Medical Clearance. If in doubt or even if the participant does exercise regularly, you may want to continue with Question 3 below. If you marked "No," you must continue with Q3 below.
Q3: Medical History:
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Have you ever had a heart attack?
Cardiac catheterization or angioplasty?
Have you had a heart transplant?
Do you have an implanted pacemaker?
Do you have an implanted defibrillator?
Are you being treated for dysrhythmia?
Do you have heart valve disease?
Do you have congestive heart failure?
Do you have a congenital heart condition?
Do you have renal (kidney) disease?
Are you taking medication for high blood pressure?
Are you taking medication for high cholesterol?
Are you taking medication for diabetes?
Are you taking medication for a heart condition?
Do you have chronic or recurring pain?
Has your doctor told you to limit your physical activity?
None of the above.
Mark all that apply.
Medical Clearance Criteria
If the participant has been experience any symptoms (Q1: Yes), the participant must
obtain medical clearance
before participating in a fitness test or light to moderate exercise.
Whether the participant is currently exercising or not (Q2: Yes or No), as long as the participant does
not
have a significant Medical History (Q3: None), the participant does
not
need medical clearance to participate in a fitness test or light to moderate exercise.
If the participant does have a significant Medical History (Q3: Yes), as long as the participant has been exercising (Q2: Yes) without symptoms (Q1: None), the participant does
not
need medical clearance to participate in a fitness test or light to moderate exercise. Medical clearance would be recommended only before engaging in vigorous exercise.
If the participant has not been exercising recently (Q2: No) and they have a significant Medical History (Q3: Yes), the participant must
obtain medical clearance
before participating in a fitness test or light to moderate exercise. The participant may need to use a facility that provides medically qualified supervision.
If you or the participant has any concerns, encourage them to talk with their personal physician and to get medical clearance for fitness testing or light to moderate exercise.
Determination:
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Medical Clearance is NOT required.
MEDICAL CLEARANCE IS REQUIRED!
Sports Medicine Technician:
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Date:
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If Medical Clearance is Required:
This form will be forwarded to your supervising Sports Medicine Specialist who will then email instructions to the participant on how to obtain medical clearance. The participant will be referred back to you if/when they obtain a signed, dated, and verifiable Medical Clearance Form from their personal physician.
Submit
Informed Consent
