• Screening Questionnaire

    This form is adapted from ISSA client assessment materials
  • PLEASE FILL OUT ALL INFORMATION BELOW
  • Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • PLEASE CHECK THE BOX FOR THE APPROPRIATE ANSWER
  • Has your doctor ever said you have heart trouble?
  • Have you ever had angina pectoris, sharp pain, or heavy pressure in your chest as a result of exercise, walking, or other physical activity such as climbing stairs? (Note: This does not include the normal out of breath feeling that results from normal activity)
  • Do you experience any sharp pain or extreme tightness in your chest when you are hit with a cold blast of air?
  • Have you ever experienced rapid heart action or palpitations?
  • Have you ever had a real or suspected heart attack, coronary occlusion, myocardial infarction, coronary insufficiency, or thrombosis?
  • Have you ever had rheumatic fever?
  • Do you have diabetes, hypertension, or high blood pressure?
  • Does anyone in your family have diabetes, hypertension, or high blood pressure?
  • Has more than one blood relative (parent, sibling, first cousin) had a heart attack or coronary artery disease before the age of 60?
  • Have you ever taken medications or been on a special diet to lower your cholesterol?
  • Have you ever taken digitalis, quinine, or any other drug for your heart?
  • Have you ever taken nitroglycerine or any other tablets for chest pain—tablets you take by placing under the tongue?
  • Are you overweight?
  • Are you under a lot of stress?
  • Do you drink excessively?
  • Do you smoke cigarettes?
  • Do you have a physical condition, impairment or disability, including a joint or muscle problem, that should be considered before you undertake an exercise program?
  • Are you more than 65 years old?
  • Are you more than 35 years old?
  • Do you exercise fewer than three times per week?
  • Should be Empty: