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?
2. Do you feel pain in your chest when you do physical activity?
3. In the past month, have you had chest pain when you were not doing physical activity?
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
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?
6. 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?
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
attack If male <55yrs = + 1 risk factor
If female <65yrs = + 1 risk factor
Relative Age
Father ____ Mother _____ Maximum of 1 risk factor for this
Brother ____ Sister _____ question
Son ____ Daughter _____

Cigarette Smoking YES / NO If YES (smoke regularly or given up

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
per week
Minutes
per week

Height: BMI = ____________

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

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

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

On medication = +1

Hyperlipidaemia or on Medication If not on medication:

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

LOW
MODERATE
HIGH

MAY INITIATE EXERCISE

UP TO VIGOROUS ACTIVITY NEEDS MEDICAL CLEARANCE

yes no

UP TO MODERATE INTENSITY REMARKS:

EXERCISE IS WITHHELD PENDING MED.

CLEARANCE

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