Medical Pre-Screening Form

*All fields/questions are required*
Today's Date (dd/mm/yyyy)
Choose One:
Class(es):
Age:      Date of Birth:
Social Security Number:
Name:
E-mail Address:
Address:
City:
Zip Code:
Home Phone #:
Work Phone #:
Please Check if applicable (x):  Employee of St. Mary's
   Volunteer at St. Mary's
   Employee at Bates College
Doctor's Name:
Address:
Phone:
Emergency Contact Name:
Phone:
   
Member Signature:
   
Date:
Section I
Are you a male age 45 or older? Y N
Are you a female age 55 or older? Y N

Do you have cardiovascular disease?
Please explain:



Y N

Do you have a respiratory illness?
Please Explain:




Y N
Do you have diabetes? Y N
Are you pregnant or postpartum?
Please indicate due date:  

Y N

Have you had surgery or been hospitalized within the past 12 months?
Please Explain:



Y N
Do you have a bone, joint or musculoskeletal problem that could/may be aggravated by physical activity?

If yes, please select all that apply:
Please hold control (CTRL) to select multiple options



Y N
Do you have any chest discomfort with exertion? Y N
Do you have a strong or throbbing heartbeat or a racing heart? Y N
Do you have a heart murmur? Y N
Do you have shortness of breath at rest or with mild exertion? Y N
Do you have unusual fatigue or shortness of breath with usual activities? Y N

Do you have any other medical conditions for which a physician has recomme restrictions on activity?
Please Explain:



Y N
Section II
Height:    Weight:  
Has your father or brother suffered a heart attack before age 55? Y N
Has your mother or sister suffered a heart attack before the age of 65? Y N
Do you have high blood pressure or are being treated for blood pressure problems? Please explain:



Y N
Do you have high cholesterol or are being treated for cholesterol problems? Y N
Do you currently smoke? Pick the one that applies to you:


 
Are you physically inactive?
(Inactive = less than 30 minutes of regular exercise, 3 days per week)
Y N
Section III
What are you currently taking medication for? (please check all that apply)
Blood Pressure  Cholesterol  Sugar / Diabetes  Heart (including aspirin)  Not Applicable
Other Medication Please select one or more:
Please hold control (CTRL) to select multiple options


Are you currently taking any medications that effect your heart rate? 
Please describe any barriers that keep you from exercising:

Please list your health and fitness goals.

 

 

Office Address:
HealthSteps, SMRMC
St. Mary's Auburn Campus
15 Gracelawn Road, Suite 101
Auburn, ME 04210
* Phone: 207-777-8898
* Fax: 207-753-3088
* Email: Healthsteps@stmarysmaine.com

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