Physical Readiness Assessment
Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Overview
At PueoMed, we aim to understand your currentphysical health and readiness before recommending different levels of physicalactivity. This Physical Readiness Assessment evaluates your medicalhistory, symptoms, and physical capabilities to determine a safe and effectiveapproach to exercise.This assessment is based on evidence-based toolscommonly used to evaluate patients for physical activity readiness and tominimize the risk of injury or adverse events.
Section 1: Medical History & Symptoms
I have no chronic conditions that limit my ability to engage in physical activity.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not experience chest pain, tightness, or discomfort during physical exertion.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can engage in physical activity without experiencing shortness of breath.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have not had dizziness, fainting, or loss of consciousness related to physical activity.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have no persistent joint, muscle, or bone pain that restricts my movement or physical activity.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have not had any recent injury or surgery in the past sixmonths that affects my mobility.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not take medications that impact my ability to engagein physical activity.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not have heart palpitations that make me feel faint or short of breath, and I have not been diagnosed with a cardiac arrhythmia.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have not been advised by a doctor to limit or avoid physical activity.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not experience swelling in my lower extremities unrelated to injury.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
My blood pressure is always within normal ranges, and I have not been diagnosed with high blood pressure.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have never had a mini-stroke, a stroke, and do not have risk factors such as high cholesterol, heart disease, arrhythmia, or a family history of stroke.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have no chronic lung conditions such as COPD, asthma, or pulmonary fibrosis.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have never experienced exercise-induced asthma or wheezing.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have no diabetes-related complications such as neuropathy or vision problems.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
My weight is generally considered normal, and it has remained the same or close for at least the past six months.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have consistent energy levels and do not frequently experience unexplained fatigue.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have not been diagnosed with osteoporosis or another bone disorder.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not experience frequent leg cramps or pain while walking.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have no history of anemia or low blood count.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Section 2: Physical Capabilities
I can perform daily activities (e.g., walking, climbing stairs, carrying groceries) without excessive fatigue.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can sustain moderate physical activity (e.g., brisk walking, light jogging) for at least 20 minutes without stopping.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can balance on one foot for at least 10 seconds.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can perform 10 bodyweight squats without pain or excessive fatigue.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not experience fatigue or weakness after short periods of physical activity.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can stand up from a chair without using my hands.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can walk at least one block without needing to stop.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can climb one flight of stairs without excessive shortness of breath.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can reach overhead and touch the back of my neck with both hands.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can touch my toes without bending my knees.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have good grip strength (e.g., opening jars, carrying groceries).
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can perform 5 push-ups without pain or excessive fatigue.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can get up off the floor without assistance.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can kneel and get back up without support.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not experience frequent loss of coordination or stumbling.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can maintain a plank position for at least 15 seconds.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can stand on my tiptoes without losing balance.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can carry a light load (5-10 lbs) for a short distance without difficulty.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not frequently experience muscle stiffness or tightness.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can perform a full squat and return to standing without assistance.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can walk at a brisk pace for at least 10 minutes without stopping.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can perform a single-leg step-up onto a stair or platform without difficulty.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I do not experience pain when bending or twisting at the waist.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can lift a gallon of water (8 lbs) without discomfort.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I can perform a sit-to-stand test (5 repetitions) without assistance.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Additional Information: Is there anything else you would like to share regarding your physical readiness that we should consider when creating a safe and effective physical activity plan for you?
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