Cardiovascular Fitness Procedures Manual

Exhibit 6-18. Checklist for CV Fitness exclusion questions

CV Fitness exclusion questions

Follow

script

SP

receptive

Prompt

use

Specific
comments and
notes
Yes No Yes No Yes No
Have you been hospitalized in the past 3
months?
Has a doctor ever said you should not
participate in sports or other activities because
of a health condition? (12- 19 years only)
Has a doctor ever said you have a heart
condition and that you should only do physical
activity recommended by a doctor?
Do you feel pain in your chest when you do
physical activity? (20-49 years only)
In the past month, have you had chest pain
when you were not doing physical activity?
(20-49 years only)
Probe: Have you seen a medical doctor about
your chest pain? Did the doctor tell you that
the chest pain was related to your heart?
Do you lose your balance because of dizziness?
Probe: Is this an isolated incident or does it
occur on a regular basis?
Do you ever lose consciousness?
Probes: Did this occur as a result of illness or
was it unexplained? Is this an isolated incident
or does it occur on a regular basis?
Do you have a bone or joint problem that could
be made worse by walking?
Probe: Do you think you can do the test
without injuring yourself?
Are you currently taking any prescription
medications?
Are you currently taking any prescription
medications for your blood pressure?
What is the name of this medication?
Are you currently taking prescription
medications for the following conditions:
heart condition, or prescription eye drops for
glaucoma?
Do you know of any other reason why you
should not do a treadmill test?