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Adult Pre-Exercise Screening (APSS) Form

A pre-activity health screening completed before starting an exercise program to flag cardiovascular, respiratory, or musculoskeletal risk factors.

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Name

First Name

Last Name

Date

Number

Gender

Female Male Non-binary Prefer not to say

Phone Number

Has your doctor ever told you that you have a heart condition?

Yes No

Do you feel pain in your chest during physical activity?

Yes No

Do you lose balance due to dizziness or lose consciousness?

Yes No

Have you had asthma or breathing difficulties?

Yes No

Do you have any joint or bone problems that could worsen with exercise?

Yes No

Are you currently taking any prescribed medications for a medical condition?

Yes No

Please provide details for any 'Yes' answers above

Name of Physician (if applicable)

Physician Contact Information

How often do you currently exercise?

Type of physical activity you engage in

Walking Running Weight training Swimming Team sports

Average duration of each session

Do you experience shortness of breath during light activity?

Yes No

Do you smoke or have you quit within the last 6 months?

Yes No

Do you have high blood pressure?

Yes No

Do you have high cholesterol?

Yes No

Do you have diabetes or pre-diabetes?

Yes No

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

Relationship

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