Northwestern University Fitness and Recreation Physical Activity Screening Form
Required Required Question(s)

There are inherent risks associated with engaging in physical activity.  In that regard, it is HIGHLY recommended that you consult your healthcare provider BEFORE engaging in any physical activity or exercise program. 

 


If you have ANY of the following conditions, symptoms or health issues, you may need to have medically qualified staff outside of Northwestern University's Fitness & Recreation Division assist in the guidance of your exercise program. 

 
1.

Please assess your health status by acknowledging all statements that are true.

You have had:
a heart attack
heart surgery
cardiac catheterization
coronary angioplasty (PTCA)
pacemaker/implantable cardiac defibrillator/rhythm disturbance
heart valve disease
heart failure
heart transplantation
congenital heart disease
2.

Please assess your health status by acknowledging all statements that are true.

Symptoms:
You experience chest discomfort with exertion.
You experience unreasonable breathlessness.
You experience dizziness, fainting, blackouts.
You take heart medications.
3.

Please assess your health status by acknowledging all statements that are true.

Other health issues:
You have musculoskeletal problems.
You have concerns about the safety of exercise.
You take prescription medication(s).
You are pregnant.

If you have ANY of the following conditions, symptoms or health issues, you might benefit from having qualified exercise staff assist in the guidance of your exercise program. 
 
Required 4.

Please assess your health status by acknowledging all statements that are true.
You are a man older than 45 years.
You are a woman older than 55 year or you have had a hysterectomy or you are postmenopausal.
You smoke.
Your blood pressure is greater than 140/90.
You don't know your blood pressure.
You take blood pressure medication.
Your blood cholesterol level is >240 mg/dL
don't know your blood cholesterol level.
You have a close blood relative who had a heart attack before age 55 (father or
You are diabetic or take medicine to control your blood sugar.
You are physically inactive (i.e. you get less than 30 minutes of physical activity
You are more than 20 pounds overweight.
None of the above is true.
Required 5.

By submitting my contact information below,   I hereby certify that I have read, understood and honestly answered the Physical Activity Screening Questionnaire above.  I understand that this questionnaire is not diagnostic, and is for informational purposes only.  I understand that there are inherent risks associated with physical activity.  Regardless of my answers above, I understand that it is recommended I contact my personal physician or healthcare provider prior to engaging in any physical activity or exercise program.   I agree that should my individual circumstances change which would then change my answers to any of the above questions, I will promptly notify the fitness staff, complete a new questionnaire and follow through with the recommendations above.

I understand the risks and benefits associated with engaging in physical activity and acknowledge that I have been advised by Northwestern University to consult with my personal physician before engaging in an exercise program.   Upon participation, I do hereby discharge release and hold harmless Northwestern University, its trustees, officers, agents and employees from any and all liability for damage claims or losses of any kind or character whatsoever resulting from any injury or condition I may suffer, including death, or resulting from my participation.

First Name:
Last Name:
Work Phone:
Home Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

Adapted from the American College of Sports Medicine's Health/Fitness Facility Standards and Guidelines