Njrotc Health Risk Screening Questionnaire Form printable pdf download

NJROTC HEALTH RISK SCREENING QUESTIONNAIRE

Cadet Name:_____________________________________________________________________(Printed Name)

NJROTC Unit:______________________________________________________________________High School

Date of your most recent pre-participation sports physical examination____________________________________

Part A – TO BE COMPLETED BY THE CADET AND PARENT/GUARDIAN

Directions: Please answer Yes or No to the following questions: (Do not leave any questions blank)

1. Do you have difficulty doing strenuous (great effort) exercise? ___________

2. Have you been told NOT to participate in long distance runs, such as a 1.5-mile-run? ____________

3. Have you been told NOT to do curl-ups or push-ups by a physician or other medical professional? __________

4. Do you exercise less than three times per week for at least thirty minutes? _____________

5. Have you had any broken bones or a serious accident in the last three months? _______________

6. Do you use tobacco of any kind? _______________

7. Have you experienced chest, neck, jaw or arm discomfort while doing physical activity? __________________

8. Do you have asthma or are you using an inhaler to aid in breathing?________________

9. Do you experience any shortness of breath with relatively low levels of exercise or exertion?_______________

10. In the last month have you felt any chest pain at rest? ________________

11. Do you have any known cardiac (heart) disease? _________________

12. Do you think you are overweight? _________________

13. Do you have dizzy/fainting spells, frequent headaches, or frequent back pains? ________________

14. Have you ever experienced dehydration after strenuous physical exercise? ____________________

15. Are you currently under treatment by a physician or other medical practitioner? ____________________

16. Has your mother or sister died without any explanation or suffered a heart attack before the age of 55? _______

17. Has your father or brother died without any explanation or suffered a heart attack before the age of 45? ______

18. Do you have high blood pressure or are you on blood pressure medication? ____________

19. Has a doctor ever told you that you have high cholesterol or are you on cholesterol medication? __________

20. Do you have sugar diabetes? ______________

21. Have you experienced episodes of rapid beating or fluttering of the heart? ________________

22. Do you suffer from lower leg swelling of both legs? _____________________

23. Do you have difficulty breathing or have sudden breathing problems at night? __________________

24. Do you have any personal history of metabolic disease (thyroid, renal, liver)? __________________

25. Do you have a bone, joint, or muscle problem that prevents you from doing strenuous exercises? _______

26. Have you unintentionally lost/gained more than 10 percent of your body weight since your last PFT? _______

27. Have you ever been diagnosed with Sickle Cell Trait?___________

___________________________________________

______________________________________________

Cadet Signature

Date

Parent/Guardian Signature

Date

Part B - If any of the answers to the questions above were YES, request that the following section be completed

and signed by a licensed medical doctor or registered school nurse:

Significant clinical history and/or current medication and treatment regimen of the above cadet: (Use reverse side

if necessary)

Recommended/released for participation in strenuous physical activities including the 1.5-mile-run? YES

__________________________________________________________________________

Signature of Medical Practitioner

Date

CNET Form 1533/106 (09-02)

Njrotc Health Risk Screening Questionnaire Form

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