GOMEZ, JONIE ROSE T.

H127TTM

PRE-PARTICIPATION SCREENING AND EXERCISE PRESCRIPTION

Objective of this exercise:

To administer pre participation screening and risk stratification for students
To write an appropriate exercise prescription and recommendations for exercise supervision.

This stage is a self-administered questionnaire

1. Has your doctor ever said that you have a heart/lung condition, stroke or diabetes and that you
should only do physical activity recommended by a doctor? NO
2. Do you feel pain in your chest when you do physical activity? NO
3. In the past month, have you had chest pain when you were not doing physical activity? NO
4. Do you lose your balance because of dizziness or do you ever lose consciousness? NO
5. Do you have a bone or joint problem (for example back, knee, or hip) that could be made worse
by a change in your physical activity? NO
6. Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or
heart condition? NO
7. Do you know of any other reason why you should not do physical activity? NO
If you answered YES to any of the 7 questions please seek guidance from your doctor or appropriate
allied health professional prior to undertaking physical activity/exercise

If you answered NO to all of the 7 questions, and you have no other concerns about your health you
may proceed to initiate physical activity/exercise

Evaluate for major symptoms/signs of CVS and presence of metabolic and pulmonary disease.
Criteria Risk Factors

Family History of heart disease (stroke, heart If male <55yrs = + 1 risk factor
attack If female <65yrs = + 1 risk factor

Relative Age Maximum of 1 risk factor for this

Father 40 Mother 40 question
Brother 18 Sister 20
Son ____ Daughter _____

If YES (smoke regularly or given up

Cigarette Smoking YES / NO within the past 6mos.) = + 1 risk factor

Physical Activity Level

If Physical Activity level < 150 mins./

week = +1 risk factor
Sedentary Light Moderate Vigorous
If Physical Activity level >150
mins./week = - 1 risk factor

(vigorous PA exercise weighted x 2

Frequency tue
per week
Minutes
per week

Low Mod High

Height: 1.65 m BMI = 24.85

Weight: 41 kg BMI > 27.5 kg/m2 = + 1 risk factor

BMI = Weight (kg) / Height (m) 2

Waist > 90cm for men and > 80cm for
Abdominal Circumference: 23 women = + 1 risk factor

Blood Pressure / or on Medication ( BP > 140mm Hg systolic or 90 mm Hg

postpone exercise if BP SBP > 200mm Hg or diastolic on 2 occasions or on
DBP > 110mm Hg medication = +1 risk factor

Hyperlipidaemia or on Medication On medication = +1

Total Cholesterol levels If not on medication:

Total cholesterol > 5.20 mmlol/L = +1
LDL levels
HDL cholesterol > 1.6mmlol/L = -1 r.f
HDL levels
HDL cholesterol < 1.0 mmlol/L = +1 r.f

LDL cholesterol > 3.40 mmlol/L = +1 r.f

Maximum 1 risk factor

Pre diabetes ( fasting glucose) Fasting glucose > 6.1 mmol = +1 r.f.
Presence of major symptoms and signs: yes no

Presence of CVD, Pulmonary or Metabolic yes no

disease

Risk level:
NEEDS MEDICAL CLEARANCE
LOW
MODERATE yes no
HIGH
REMARKS:

MAY INITIATE EXERCISE

UP TO VIGOROUS ACTIVITY
UP TO MODERATE INTENSITY
EXERCISE IS WITHHELD PENDING MED.
CLEARANCE