Adult Pre-Exercise Screening (APSS) Form
This screening form is designed to assess your readiness for physical activity and identify any health conditions that may require medical clearance before participating in exercise. Please answer all questions honestly and accurately.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Number
Gender
Male
Female
I don't want to mention
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Health Screening (Stage 1)
Has your doctor ever told you that you have a heart condition?
Yes
No
Do you feel pain in your chest during physical activity?
Yes
No
Do you lose balance due to dizziness or lose consciousness?
Yes
No
Have you had asthma or breathing difficulties?
Yes
No
Do you have any joint or bone problems that could worsen with exercise?
Yes
No
Are you currently taking any prescribed medications for a medical condition?
Yes
No
Medical Details (Conditional Section)
Please provide details for any “Yes” answers above
Name of Physician (if applicable)
Physician Contact Information
Lifestyle & Activity Level (Stage 2)
How often do you currently exercise?
Please Select
Once a week
Once a day
More than once a week
More than once a day
Type of physical activity you engage in
Cardio
Calisthenics
Fitness
Average duration of each session
Please Select
Half an hour
An hour
More than an hour
Do you experience shortness of breath during light activity?
Yes
No
Risk Factors (Stage 3)
Do you smoke or have you quit within the last 6 months?
Yes
No
Do you have high blood pressure?
Yes
No
Do you have high cholesterol?
Yes
No
Do you have diabetes or pre-diabetes?
Yes
No
Emergency Contact
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Submit
Should be Empty: