Health Qualification – Pike Fitness®

Name*

First Last

Email*

Date of Birth*

Phone*

Sex*

Male
Female

Exercise Readiness Questionnaire

Has a physician ever diagnosed you with a cardiac, peripheral vascular, or cerebrovascular disease?*

Yes
No

Has a physician ever diagnosed you with chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, or cystic fibrosis?*

Yes
No

Has a physician ever diagnosed you with diabetes mellitus (type 1 and 2), thyroid disorder, renal or liver disease?*

Yes
No

Do you feel pain in your chest when performing physical activity?*

Yes
No

Have you experienced chest pain while not exercising within the past month?*

Yes
No

Do you lose your balance because of dizziness, or do you ever lose consciousness?*

Yes
No

Do you have a bone or joint problem that could be worsened by a change in your level of physical activity?*

Yes
No

Is your doctor currently prescribing pills for your blood pressure or a heart condition?*

Yes
No

Are you pregnant?*

Yes
No

Do you experience swelling of the ankles?*

Yes
No

Do you experience pain, aches, cramps or tiredness in the calves, feet, thighs, hips, or buttocks muscles?*

Yes
No

Do you experience discomfort when not in upright position, or interrupted breathing at night?*

Yes
No

Do you ever experience shortness of breath?*

Yes
No

Do you have a heart murmur?*

Yes
No

Do you experience pain or discomfort in the jaw, neck, chest, arms or elsewhere that could be caused by lack of circulation?*

Yes
No

Coronary Artery Disease Risk

Are you over 45 years of age or older?*

Yes
No

Are you over 55 years of age or older?*

Yes
No

Has a 1st degree relative ever died from sudden death, had a heart attack, or had coronary revascularization?*

Yes
No

1st degree relative = parent, sibling or child

At the time of your relatives accident or surgery, were they a male under 55 years old, or a female under 65?

Yes
No

Do you smoke or have you quit smoking within the last 6 months? Are you around 2nd hand smoke?*

Yes
No

Do you have high cholesterol?*

Yes
No

High cholesterol = LDL ≥130 mg/dl or HDL of <40 mg/dl or on lipid lowering medication. If total serum cholesterol is all that is available, use ≥ 200 mg/dl

Are you diabetic or prediabetic?*

Yes
No

Prediabetic = elevated blood glucose levels ≥ 100mg/dl, or 2-hour values in an oral glucose tolerance test ≥ 140 mg/dl on at least two separate occasions.

Are you obese?*

Yes
No

BMI ≥ 30 kg/m² or waist circumference of >40” for men and >35” for women

Are you sedentary?*

Yes
No

Sedentary = getting less than 30 minutes of meaningful activity on all or most days of the week -or- Less than 30 minutes of moderate activity (40-60% V02 Reserve) on at least three days per week for at least three months.

Are you hypertensive?*

Yes
No

Systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg confirmed by two separate occasions or currently on antihypertensive medication

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