Fitness Screening Questionnaire

You are being asked these questions for your safety and health. The AF Fitness Assessment (FA) is a maximum-effort

test. Airmen who have not been exercising regularly and/or have other risk factors for a heart attack (increasing age,

smoking, diabetes, high blood pressure, etc.) are at increased risk of injury or death during the test. Answering these

questions honestly is in your best interest.

1. Have you experienced any of the symptoms/problems listed below and not been medically evaluated and cleared for

unrestricted participation in a physical training program?

 Unexplained chest discomfort with or without exertion

 Unusual or unexplained shortness of breath

 Dizziness, fainting, or blackouts associated with exertion

 Other medical problems that have not been evaluated, optimally treated, or not already addressed in an AF Form

469, that may prevent you from safely participating in this test (e.g. heart disease, sickle cell trait, asthma, etc.).

 Family history of sudden death before the age of 50 years

 Yes: Stop. Notify your UFPM and contact your PCP/MLO for evaluation/recommendations (or for ARC, contact

the MLO for Duty Limiting Conditions (DLC) documentation and referral to PCP). Hand carry this form

to medical evaluation.

 No: Proceed to next question.

2. Are you 35 years of age or older?

Yes: Proceed to next question.

No: Stop. Sign form and return to your UFPM. Member may take the FA.

3. Have you engaged in vigorous physical activity (i.e., activity causing sweating and moderate to marked increases in

breathing and heart rate) averaging at least 30 minutes per session, 3 days per week, over the last 2 months?

Yes: Stop. Sign form and return to your UFPM. Member may take the fitness assessment.

No: Proceed to the next question.

4. Do one (1) or more of the following risk factors apply to you?



Smoked tobacco products in the last 30 days



Diabetes



High blood pressure that is not controlled



High cholesterol that is not controlled



Family history of heart disease (developed in father/brother before age 55 or mother/sister before age 65)



Age > 45 years for males; > 55 years for females

Yes: Stop and notify UFPM.

 No: Stop. Sign form and return to your UFPM. Member will take the FA.

If member experiences any of the symptoms listed in Question #1 during the fitness assessment, he/she should stop

the test immediately and seek medical attention immediately

Signature: _______________________________________

Date: __________

Printed Name: ___________________________________

Rank: __________

Duty Phone: _____________________________________

Office Symbol: __________

Authority: 10 USC 8013. Routine Use: This information is not disclosed outside DoD. Disclosure is Mandatory. Failure to

provide this information may result in either administrative discharge or punishment under the UCMJ.

Fitness Screening Questionnaire - Dyess Fss

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