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. NO - 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?
2. NO - Do you feel pain in your chest when you do physical activity?
3. NO - In the past month, have you had chest pain when you were not doing physical activity?
4. NO - Do you lose your balance because of dizziness or do you ever lose consciousness?
5. NO - 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?
6. NO - Is your doctor currently prescribing drugs (for example water pills) for your blood pressure
or heart condition?
7. Do you know of any other reason why you should not do physical activity?
I can only run 184.04m at a time.
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 No family heart disease history.   No
attack

Relative Age
Father ____ Mother _____
Brother ____ Sister _____
Son ____ Daughter _____
 Not smoking No
Cigarette Smoking: NO

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 2 twice
per week
Minutes 30
per week

Low Mod High

Height: 178cm BMI = 20.5 kg/m2

Weight: 64.90 BMI > 27.5 kg/m2 = + 1 risk factor

BMI = 20.5 kg/m2

Waist > 90cm for men and > 80cm for
Abdominal Circumference: 78.74cm 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