Fitness Screening Questionnaire Template Page 2

 

Member   S ignature:   _ ______________________________________                           D ate:   _ _________

Member   P rinted   N ame:   _ __________________________________                             R ank:   _ _________

Duty   P hone:   _ ____________________________________                                                             O ffice   S ymbol:   _ _________

Authority:   1 0   U SC   8 013.   R outine   U se:   T his   i nformation   i s   n ot   d isclosed   o utside   D oD.     D isclosure   i s   M andatory.     F ailure   t o   p rovide  

this   i nformation   m ay   r esult   i n   e ither   a dministrative   d ischarge   o r   p unishment   u nder   t he   U CMJ.

Medical   E valuation   ( Only   a pplicable   t o   t hose   w ho   m arked   Y es   o n   Q uestion   1 )

If   m edical   e valuation   i s   r equired   I AW   t his   F SQ,   t he   p rovider   w ill   c omplete   t he   f ollowing.

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I   m edically   e valuated   _ _________________________________   o n   _ _____________.    

                                                                                                                                           

                                                                   

( rank,   n ame)  

( date)

Medical   r ecommendations   a re:

                                                                                                                                                                                                                                                                                     

Member   ( is/is   n ot)   m edically   c leared   f or   t he   m aximal   e ffort   1 .5-­‐mile   r un.

Member   ( is/is   n ot)   m edically   c leared   f or   t he   m aximal   e ffort   1 .0-­‐mile   w alk.

Member   ( is/is   n ot)   m edically   c leared   f or   p ush-­‐ups.  

Member   ( is/is   n ot)   m edically   c leared   f or   s it-­‐ups.

NOTE:     A n   A F   F orm   4 69   h as   b een   i nitiated   i f   a ppropriate.     A irmen   w ith   f itness   l imitations   g reater   t han   3 0   d ays   m ust   b e   r eferred   t o  

the   E P/FPM   f or   f itness   p rescription   I AW   A FI   3 6-­‐2905.

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(Signature/Stamp   o f   P rovider)