Exercise Pre-Participation Screening Questionnaire Form
Exercise Pre-Participation Screening Questionnaire Form for participants to complete before exercise activity. Provide the requested screening information so participation can be reviewed.
Participant Information
Participant full name
*
First Name
Middle Name
Last Name
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact phone number or email address
*
Emergency and Exercise Background
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Exercise Type or Sport
*
Please Select
Running
Walking
Cycling
Swimming
Strength Training
Yoga
Team Sport
Martial Arts
Other
Usual Exercise Frequency per Week
*
Please Select
0-1 times
2-3 times
4-5 times
6+ times
Pre-Participation Screening Questions
Do you experience chest pain or discomfort during exercise?
*
No
Yes
During activity, do you experience dizziness, fainting, or unexplained shortness of breath?
*
No
Yes
Have you been told you have a heart condition or to limit exercise, or do you have a current injury, pain, condition, or medication/health concern we should know about for safe participation?
*
No
Yes
Submit
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