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Pre-Activity Screening Form
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First name:
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Last name
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Cell or Home Phone
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Work Phone
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Email address:
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Gender
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Date of Birth
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Has your physician or provider ever told you that you have a heart condition?
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No
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Do you experience pain in your chest when you are physically active
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No
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Do you lose balance because of dizziness or do you ever lost consciousness?
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No
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Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity?
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No
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Is your physician or provider currently prescribing medications for your blood pressure or a heart condition?
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No
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Do you currently participate in any rehabilitative medicine programs (physical, occupational, cardiac or other rehabilitation)?
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Yes
No
If you answered “yes” to any of these questions, you may be eligible to qualify for our medical fitness program. You will be contacted by a representative of Labette Health’s The CORE and be invited to participate in a complete Wellness Profile to determine specific need areas.
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