Fitness Screening Questionnaire Template
Download a blank fillable Fitness Screening Questionnaire Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Fitness Screening Questionnaire Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2FITNESS
S CREENING
Q UESTIONNAIRE
You
a re
b eing
a sked
t hese
q uestions
f or
y our
s afety
a nd
h ealth.
T he
A F
F itness
A ssessment
i s
a
m aximum-‐effort
t est.
A irmen
who
h ave
n ot
b een
e xercising
r egularly
a nd/or
h ave
o ther
r isk
f actors
f or
a
h eart
a ttack
( increasing
a ge,
s moking,
d iabetes,
h igh
blood
p ressure,
e tc.)
a re
a t
i ncreased
r isk
o f
i njury
o r
d eath
d uring
t he
t est.
A nswering
t hese
q uestions
h onestly
i s
i n
y our
b est
interest.
1.
Have
y ou
e xperienced
a ny
o f
t he
s ymptoms/problems
l isted
b elow
a nd
n ot
b een
m edically
e valuated
a nd
cleared
f or
u nrestricted
p articipation
i n
a
p hysical
t raining
p rogram?
a. Unexplained
c hest
d iscomfort
w ith
o r
w ithout
e xertion
Y es
N o
b. Unusual
o r
u nexplained
s hortness
o f
b reath
Y es
N o
c. Dizziness,
f ainting,
o r
b lackouts
a ssociated
w ith
e xertion
Y es
N o
d. Other
m edical
p roblems,
n ot
a lready
a ddressed
i n
a n
A F
F orm
4 69,
t hat
m ay
p revent
y ou
f rom
s afely
participating
i n
t his
t est
o r
a chieving
a
s atisfactory
s core
Yes:
S
top.
N otify
y our
U FPM
a nd
c ontact
y our
P CP/MLO
f or
e valuation/recommendations
( or
f or
Y es
ARC,
c ontact
t he
M LO
f or
D uty
L imiting
C onditions
( DLC)
d ocumentation
a nd
r eferral
t o
P CP).
No:
P roceed
t o
n ext
q uestion.
N o
Are
y ou
3 5
y ears
o f
a ge
o r
o lder?
.
Yes:
P roceed
t o
n ext
q uestion.
Y es
No:
S top.
S ign
f orm
a nd
r eturn
t o
y our
U FPM.
M ember
m ay
t ake
t he
f itness
a ssessment
N o
Have
y ou
e ngaged
i n
v igorous
p hysical
a ctivity
( i.e.,
a ctivity
c ausing
s weating
a nd
m oderate
t o
.
marked
i ncreases
i n
b reathing
a nd
h eart
r ate)
a veraging
a t
l east
3 0
m inutes
p er
s ession,
3
d ays
p er
week,
o ver
t he
l ast
2
m onths?
Yes:
S
top.
S ign
f orm
a nd
r eturn
t o
y our
U FPM.
M ember
m ay
t ake
t he
f itness
a ssessment.
Y es
No:
P roceed
t o
t he
n ext
q uestion
N o
Do
o ne
( 1)
o r
m ore
o f
t he
f ollowing
r isk
f actors
a pply
t o
y ou?
.
a. Smoked
t obacco
p roducts
i n
t he
l ast
3 0
d ays
Y es
N o
b. Diabetes
Y es
N o
c. High
b lood
p ressure
t hat
i s
n ot
c ontrolled
Y es
N o
d. High
c holesterol
t hat
i s
n ot
c ontrolled
Y es
N o
e. Family
h istory
o f
h eart
d isease
( developed
i n
f ather/brother
b efore
a ge
5 5
o r
m other/sister
b efore
a ge
Y es
N o
65)
f. Age
>
4 5
y ears
f or
m ales;
>
5 5
y ears
f or
f emales
Y es
N o
Yes:
S top
a nd
n otify
U FPM.
Y es
No:
S top.
S ign
f orm
a nd
r eturn
t o
y our
U FPM.
M ember
m ay
t ake
t he
F A.
N o
Notes:
R egAF
o r
A NG
( Title
1 0)
s tatutory
t our
a nd
A GR:
I f
m ember
w as
c leared
f or
e ntry
i nto
a
f itness
p rogram
a t
t heir
l ast
P HA
and
t heir
P HA
i s
c urrent,
t he
m ember
w ill
t ake
t he
f itness
a ssessment.
I f
n ot
c leared,
m ember
w ill
b e
r eferred
t o
P CM
f or
evaluation,
a nd,
i f
m edically
c leared
f or
u nrestricted
f itness
p rogram,
t he
m ember
w ill
t ake
t he
F A.
AFR:
I f
m ember
w as
c leared
f or
p articipation
i nto
a
f itness
p rogram
a t
a
P HA
w ithin
t he
l ast
1 2
m onths,
t he
m ember
w ill
t ake
t he
fitness
a ssessment.
I f
n ot
p reviously
c leared,
m ember
w ill
b e
r eferred
t o
P CP
f or
e valuation,
a nd,
i f
m edically
c leared
f or
unrestricted
f itness
p rogram,
t he
m ember
w ill
t ake
t he
f itness
a ssessment.
R efer
t o
M LO
i f
t here
i s
a ny
c ombination
o f
s moking,
diabetes,
u ncontrolled
h igh
b lood
p ressure,
a nd/or
u ncontrolled
h igh
c holesterol.
M LO
w ill
u pdate
m edical
r ecords
a nd/or
i nitiate
DLC
d ocumentation.
ANG
( Title
3 2):
R efer
t o
M LO
i f
t here
i s
a ny
c ombination
o f
s moking,
d iabetes,
u ncontrolled
h igh
b lood
p ressure,
a nd/or
uncontrolled
h igh
c holesterol.
M LO
w ill
u pdate
m edical
r ecords
a nd/or
i nitiate
D LC
d ocumentation.
If member experiences any of the symptoms listed in Question #1 during the fitness assessment, they should stop the test
immediately and seek medical attention immediatly.
(OVER)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life