Inova FitNET ~ Pre-Screening Form

Inova FitNET Pre-Participant Medical Screening Form

To be filled out online prior to accepting any possible participants to the program.

Has a doctor ever said that you have a heart condition and recommended only medically
supervised activity?
Have you ever had a heart attack, heart surgery, cardiac catheterization, coronary angioplasty,
pacemaker/implantable cardiac defibrillator, cardiac rhythm disturbance, heart valve disease,
heart failure, a heart transplant, or congenital heart disease?
Do you have chest pain brought on by physical activity?
Have you developed chest pain in the past month?
Was your blood pressure 140/90 or higher at your last check OR do you not know what your
blood pressure is?
Has a doctor ever recommended medication for your blood pressure or a heart condition?
Have you been prescribed medication to control your blood sugar?
Have you on 1 or more occasions lost consciousness or fallen over as a result of dizziness?
Do you have a bone or joint problem that could be aggravated by the proposed physical
activity?
Are you pregnant?
Are you aware, through your own experience or a doctor's advice, of any other physical reason
that would prohibit you from exercising without medical supervision?

If you answered "yes" to any of these questions, call your personal physician or healthcare provider
before increasing your physical activity. You must have a physician’s written consent to participate in
Inova FitNET.

Adapted from: Physical Activity Readiness Questionnaire (PAR-Q) and the AHA/ACSM Health/Fitness Facility
Pre-participation Screening Questionnaire