OSU Allergies Hypercholesterolemia & Diabetes Mellitus Questions

DescriptionLABORATORY 12
Musculoskeletal Fitness
Measurements
Objectives
• Become familiar with various methods of evaluating
muscular strength and endurance
• Differentiate between direct and indirect methods of
determining muscular strength
• Understand proper methods for performing a 1RM bench
press and leg press
• Introduce prediction equations used to estimate muscular
strength
Introduction
• Muscular fitness
• Combination of muscular endurance and muscular strength
• High fitness associated with positive health status
• Part of comprehensive health and wellness screening
• Healthy musculoskeletal system associated with improved
ability to complete daily living activities
• Improved quality of life
(continued)
Introduction (continued)
• Muscular strength
• Highest amount of force that can be generated by a muscle during
single contraction
• Muscular endurance
• Ability to exert submaximal forces repetitively
• Tests of muscular fitness selected based on muscle group,
available equipment, and subject capabilities
Assessments of Muscular Strength
• No total-body muscular fitness testing
• Specific to certain factors
• Muscle groups tested
• Velocity of movement used
• Type of contraction and ROM
• Type of equipment
• Difficult to compare individual results with scientific
literature
Considerations of Muscular Fitness
Assessments
• Familiarize self with equipment and protocol
• Perform protocol under standardized conditions
• Six steps
• Increase accuracy and reliability
• Dynamic or static methods
ACSM Recommendations
1RM Testing
• Gold standard of dynamic muscular strength
• Maximal force exerted dynamically through a ROM
• Controlled
• Maintaining proper technique
• Client familiarization crucial
• High test–retest reliability
Methods of 1RM Procedure
• Have subject estimate his or her 1RM
• Trained versus untrained
• Warm up with 5 to 10 repetitions
• 40% to 60% of perceived maximum
• After 1 minute of rest, subject performs 3 to 5 repetitions
• 60% to 80% of perceived maximum
• After 3 minutes rest, subject performs 1 repetition
• ~90% of perceived maximum
(continued)
Methods of 1RM Procedure (continued)
• Make conservative increases in resistance, then have
subject perform 1 repetition
• If successful, rest for 3 minutes, then make another attempt
with increased load
• Continue until subject is unable to complete repetition with
good technique
• 1RM is heaviest weight successfully completed
Considerations of 1RM Testing
• Considered safe for most populations
• Test supervisor must assess client’s technique
• Can report heaviest load (kg) individual listed
• Track client’s fitness over time
• Divide 1RM by body mass and compare to normative data
• Comparing individuals
• Tables 12.2 and 12.3
Norms for 1RM Bench Press
Norms for 1RM Leg Press
Predicting 1RM
• Strength endurance test may be recommended when 1RM
not feasible
• Indirect method of determining muscular strength
• Percentage of 1RM load decreases by 2% to 2.5% per
maximal repetition performed
• 1RM load is maximal resistance that can be lifted one time
• Repetition maximum test and prediction equations
Estimating 1RM
• Repetition Maximum (RM) test
• Strength endurance test
• Performed with a load that can handle 5 to 10 repetitions
• Established load can be used with 1RM estimation table
(12.5)
• Predict client’s maximal muscular strength
Using 1RM Prediction Equations
• Allows client to perform 1mm indicates ischemia and or MI (emergency medical
attention necessary)
Lab 16

Irregular ECGs: Premature Ventricular and Atrial contractions
Lab 16

Irregular ECGs: Atrial flutter (sawtooth) & Atrial Fibrillation
Lab 16

Irregular ECGs: Asystole & Ventricular Fibrillation

Which one can you use an AED?
Lab 16

ECGs and Exercise:
 HR will increase where the frequency of contraction increases
 Due to parasympathetic withdraw and sympathetic activation
 A person may exhibit increased rates of PVCs and PACs
 Drastic increases are cause for concern
 Exercise increases the myocardial demands (requires more oxygen)
 The ECG may show signs of ST depression/elevation
 Intensity at which this appears is the ischemic threshold


Used as a guide to exercise intensity in cardiac rehab
Normal, healthy individuals can have PVCs and PACs at any point
Performing an ECG at rest or exercise

Criteria for terminating a clinical exercise test with ECG
 Absolute Indications
 ST elevation >1.0mm
 Drops in SBP >10 mmHg w/ increased workload
 Moderate-severe angina
 CNS symptoms (ataxia, dizziness, syncope)
 Poor perfusion (cyanosis, pallor)
 Sustained Vtach or other arrhythmia such as heart block
 Difficulty monitoring ECG
 Request to stop
Performing an ECG at rest or exercise

Criteria for terminating a clinical exercise test with ECG
 Relative Indications
 ST displacement (downsloping > 2mm)
 Drop in SBP > 10 mmHg w/ increased workload
 Increasing chest pain
 Fatigue, SOB, wheezing, leg cramps, claudication
 Other arrhythmias that may progress to more complex
 Exaggerated BP response (>250 mmHg SBP, 115 mmHg DBP)
 SpO2 200 mg/dl
Doesn’t know blood cholesterol
Close relative had heart attack before age 55 (father or brother) or age 65 (mother or
Physically inactive (does not engage in >30 min of physical activity more than 4 days/wk)
DD
Overweight by more than 20 lb (9 kg)
From G. Ha ff and C. Dumke, 2012, L&borafory 77?¢72#czJ/o7. cxe7.c3.se Pkys2.oJogy (Champaign, IL: Human Kinetics). Adapted,
by permission, from V. Heyward, 2010, Adz/cz73cedfi£7?ess c!ssess77?e73C cz7ed exerc3.se P7.escr?.PC8.o73, 6th ed. (Champaign, IL: Human
Kinetics), 320-321.
68
John Doe
2800 W Gore Blvd
999-999-9999
7/26/1966
0000001
John Doe
Patient directed glucose monitoring before and after exercise.
Dr. Richard Roe
999-999-0000
12/2/2021
Fitness Assessment
Client/Patient Name:
Date of Birth: 7/26/1966
Ethnicity:
RHR (bpm):
69
RBP (mmHg): 144 / 78
Today’s
Date: 12/1/2021
Gender: Male
John Doe
Age (y):
55
Referring Physician (if applicable):
Height (in):
75
Height (m):
1.905
Flexibility
Backsaver Sit-and-reach: 19 cm
Back Scratch Test: -2.4 cm
Muscular
Endurance/Strength
YMCA Bench Press: 23 Reps @ 80
kg
Predicted Bench Press 1 RM: 162
lbs.
Weight (lb): 280
Weight (kg): 127.01
Rank:
Rank:
40th percentile
Below Average
Rank: 80%
Predicted Relative 1RM: 0.58
Relative 1RM:
1.36
1 RM Leg Press: 380 lbs.
Cardiorespiratory Fitness
Stage/Minute
0/0
1/3
2/6
3/9
3/10
Speed Grade
0
0
1.7
10
2.5
12
3.4
14
3.4
14
HR
69
98
134
150
156
VO2(L/min) VO2(mL/min
1.09
1.68
2.74
2.9
9.8
15.5
21.5
22.7
VE
METs
VCO2
RER
RPE
30.9
46.2
60.5
68.6
4.6
7
10.2
10.2
0.91
1.25
3.2
3.42
0.83
0.74
1.17
1.18
13
15
17
19
Notes: Client requested to stop at 10 minutes due to severe fatigue.
Form 2.1
Informed consent Form
John Doe
have been informed that I will`
perform a series of tests in order to determine my physical fitness status as well as enhance my understanding of my own health and physical fitness status. I understand that I can voluntarily withdraw from
these tests at any time without any penalty. Additionally, I understand that I can ask questions about
the tests at any time and will have those questions answered to my satisfaction. In the event of any side
effects or injuries related to these tests, I understand that I may contact
at any time with my concerns.
Explanation of Tests:
I,
John Doe
Lab Student
understand that I will fill out a series
of questionnaires including a health history questionnaire and a PAR-Q in order to ensure my safety
during the testing process. I understand that if these questionnaires reveal that I am at significant risk
of an adverse event then no further tests will be conducted. I understand that if the questionnaires
reveal little risk to my safety, I will perform the remainder of the assessments. I will have my blood
pressure, body weight, and height assessed with methods typically used in a physician’s office. After
completing these assessments, I will have my body composition measured by Lab Student
which will evaluate how much fat and fat-free mass my body contains. I will then perform an assessment of my muscular strength and endurance, which will require me to lift weights for a number of
After completing this assessment,I will perform a graded
repetitions using a Free-Weight/Body Weight
exercise test on a Treadmill, Cycle, or Step in which the workload increases every few minutes until
exhaustion or until the test is terminated. I understand that this assessment will give insight into my
cardiorespiratory fitness.
Risks and Discomforts:
lt has been explained to me that during a graded exercise test, certain
physical changes can occur, including abnormal blood pressure responses, fainting, irregular heartbeat, and in some instances fatal heart attacks. In order to minimize these risks, the personnel conducting the test are trained to handle such adverse effects. Additionally, they are trained to recognize
#::i:a|tY%j’:#t,S:gnnds::8yw::;t::s:tT:nt:Sr:nogf:::jems:,ar::Sket:umne::r;:::da[shoatbteheenTn::::r:dmtehnatt°tfhe
assessment of muscular strength and endurance involves some risk of pulling or spraining a muscle and
that these risks will be minimized by employing a proper warm-up period and by means of technical
monitoring by the testing staff. I also understand that after the completion of the testing bouts, I may
experience some local muscle soreness that may last for 24 to 48 hours.
If muscle soreness does I occur, I understand that I can perform a series of stretches that have been
demonstrated to me by the testing staff. If these symptoms persist, I will report them to
Lab Student, other facility staff, and/or physician.
Benefits From Testing:
I understand that the results of these tests will give insight into my overall
physical health and wellness. Additionally,I have been informed that this information will reveal any
potential health hazards and can be used to better individualize my exercise program.
Inquiries:
I understand that if I have any questions, I can ask them of the testing staff. These questions will be answered to my satisfaction by the testing staff.
Confidentiality:
I understand that all of my personal health and physical fitness data will be kept
confidential.
(continued)
57
Form 2.1
(c.o#f!.73z{ec!/
I have read the information contained in this document and understand it. All questions pertaining to
the procedures that I am volunteering to undergo have been answered to my satisfaction. I understand
that I am free to decline answering any questions and to withdraw from this testing at any time without
penalty. Additionally,I have been informed that all of the information gathered about me and the tests
undertaken by me are confidential and will not be disclosed to anyone but me or others in my care or
used for exercise prescription without my written permission. Finally, I am aware of all risks associated
with this testing and voluntarily give my consent to participate in this testing.
12/1/2021
Signature of patient/client
12/1/2021
Signature of witness
Signature of supervisor
From G. Ha ff and C. Dumke, 2012, L¢bo7.cz!ory 7%a7?G/cz//or exe7.c3.se Pkys3.a/ogy (Champaign, IL: Human Kinetics). Adapted,
by permission, from D.C. Nieman, 2003, Exe7.c3.se Zesc€.7€g cz7€dp7.escr€.p£3.o7¢.. 4 feecz/£%-7.eJczlecz czPP7.oczcfe, 5th ed. (New York, NY:
MCGraw-Hill), 774. ©The MCGraw-Hill Companies.
58
Form 2.3
Health History Questionnaire
Contact Information
John
Doe
First name
Last name
55
7/26/1966
Date of birth (mm/dd/yy)
Middle initial
Sex: I Male I Female
Age
2800 W Gore Blvd
Lawton, Ok
73505
Home phone number
Street address
City, State
Zip code
Jane Doe
999 999
(–
999
IIIIIIE
999
9999
Emergency contact
Wife
9999
Relationship to emergency contact
Emergency contact number
Dr. Richard Roe
999 999
IIIIIIE-
Primary physician
Physician’s contact number
0000
Background
Please circle the highest school grade you have completed:
Primary:
1
2
3
4
Secondary:
9
10
11
12
College/postgrad:
13
Whatisyourmaritalstatus?
14
Dsingle
15
16
I Married
5
6
7
8
17
18
19
20+
Dwidowed
DDivorcedorseparated
What is your race or ethnic background?
D white, not of Hispanic origin
I Black, not of Hispanic origin
I American Indian/Alaskan native
I Asian
D pacific Islander
I Hispanic
What is your occupation?
DHea|th professional
DDisabled, unabletowork
Eservice
D¥raonf:gs::neaqucat°r’
Dskilled crafts
DOperator, fabricator, laborer
DHomemaker
DTechnical, sales, support
I Retired
I unemployed
I student
I other: Owner/Operator of a moving company
Symptoms or Signs Suggestive of Disease
Please place a check the appropriate box:
Yes
No
I
I
I
D
Have you experienced any unusual pain or discomfort in your chest, neck, jaw, arms, or
other areas that may be due to heart problems?
Have you experienced unusual fatigue and/or shortness of breath at rest, during usual
activities (e.g., climbing stairs, carrying groceries, walking briskly) or during mild or
moderate exercise?
I
D
Have you ever had any problems with dizziness or fainting?
I
I
When you stand up, do you have difficulty breathing?
I
I
Do you have difficulty breathing while sleeping?
I
D
Do your ankles swell (ankle edema)?
(continued)
61
Form 23
(continued)
Yes
No
D
I
Have your ever experienced an unusual or rapid heartbeat or fluttering of the heart?
I
I
Have you experienced severe pain in your legs while walking?
I
I
Have you ever been told by a doctor thatyou have a heart murmur?
Chronic Disease Risk Factors
Do you knowyourblood pressure?
I =Yes:
Doyou knowyourcholesterol levels?
I =Yes:
260
Doyou knowyourfasting glucose levels?
I =Yes:
/_systolic/diastolic
I = No
200
total cholesterol;_HDL;_LDL
34
98 mg/dl
I = No
I = No
Please place a check in the appropriate box:
Yes
No
I
D
I
I
lfyou are a female, have you experienced premature menopause and are not on
estrogen replacement therapy?
I
I
Has your father or brother had a heart attack or died suddenly from heart disease
before the age of 55?
I
I
Has your mother or sister had a heart attack or died suddenly from heart disease
before the age of 65?
I
I
Has anyone in your family died before the age of40 (excluding accidental death)?
I
I
Are you a current cigarette smoker?
I
I
Has a doctor told you that you have high blood pressure (more than 130/80)?
D
I
Areyou a male overthe age of45 ora female overthe age of55?
Are you on medication to control high blood pressure?
I
I
Has a doctor evertold you that you have high cholesterol?
I
D
ls your serum cholesterol greaterthan 200 mg/dl?
I
D
Do you have diabetes mellitus?
D
I
Are you physically inactive or sedentary (i.e., do you perform little physical activity on
the I.ob or during leisure time)?
I
I
I
D
During the past year, have you experienced levels of stress, strain, and pressure that
might affect your health?
Do you eat foods that are high in fat and cholesterol, such as fatty meats, cheese, fried
food, butter, whole milk, or eggs on a daily basis?
I
I
Do you tend to avoid foods that are high in fiber, such as whole-grain breads and
cereals, fresh fruits, and vegetables?
I
E
Do you weigh 30 pounds more than you should?
I
I
Do you average more than two alcoholic beverages a day?
Medical History
Please check all conditions that you or your family have had or now have.
Your
You
62
Your
family
You
family
DD
Coronary heart disease, heart
attack, coronary artery surgery
I
I
Peripheral vascular disease
DD
Angina
I
I
Phlebitis or emboli
Your
Your
You
family
You
family
I
I
Other heart problems (Specify:
DD
Major injury to foot, leg, knee,
hip, or shoulder
I
I
Lung cancer
I
I
Major inj.ury to back or neck
I
I
Breast cancer
I
I
Stomach or duodenal ulcer
I
I
Prostate cancer
I
I
Rectal growth or bleeding
I
I
Colorectal cancer (bowel cancer)
I
I
Cataracts
D
I
Skin cancer
I
I
Glaucoma
I
I
Other cancer (Specify:
I
I
Hearing loss
)D
I
Depression
D
I
High anxiety, phobia
D
D
I
I
I
Stro ke
I
I
Chronic obstructive pulmonary
disease (emphysema)
I
Pneumonia
I
I
Asthma
I
I
Bronchitis
I
I
Diabetes mellitus
I
I
Thyroid problems
I
.
Kidney disease
I
I
Liver disease (cirrhosis of the
liver)
D
.
Hepatitis (A, B, C, D, or E)
D
I
Gallstone/gallbladder disease
D
I
Osteoporosis
I
I
Arthritis
I
I
Gout
I
I
Anemia (low iron)
I
I
Bone fracture
I
I
I
D
I
B
I
Substance abuse problems (e.g.,
alcohol, drugs)
I
Eating disorders (anorexia,
bulimia)
I
Problems with menstruation
I
Hysterectomy
I
Sleeping problems
I
Allergies
I
H IV/AIDS
I
Any other problems (please
be specific and include information on any recent illnesses,
hospitalizations, or surgical
procedures):
Low-back pain on most days at work.
Medications
Please check any of the following types of medication that you currently take regularly. Also give the
name of the medication.
Type of medication
Name of medication
I Heart medicine
I Blood pressure medicine
I Blood cholesterol medicine
I Hormones
I Birth control pills
I Medicine for breathing or lungs
B Insulin
I Other medicines for diabetes
Metformin
(continued)
63
Form2.3
(continued)
I Arthritis medicine
I Medicine for depression
I Medicine for anxiety
I Thyroid medicine
I Medicine for ulcers
I Painkiller medicine
I Allergy medicine
I HIV/AIDS medicine
I Hepatitis medicine
Nandrolone (for low testosterone)
I Other (please specify)
Physical Fitness, Physical Activity, and Exercise
ln general, compared with other persons your age, rate how physically fit you are:
1
2
3
4
5
6
7
8
9
10
D.DDDDDDDD
Not at all fit
Somewhat fit
Extremely fit
Outside of your normal work or daily responsibilities, how often do you engage in exercise that at
least moderately increases your breathing and heart rate, and makes you sweat, for at least 20 minutes
(e.g., brisk walking, cycling, swimming, aerobic dance, stair climbing, rowing, basketball, racquetball,
vigorous yardwork).
D5ormoretimesperweek
D3or4timesperweek
I Lessthan once aweek
. Seldom or never
I 1 or2timesperweek
How much hard physical work is required on your job?
I A great deal
I A moderate amount
I A little
I None
How long have you exercised or played sports regularly?
D I do notexercise regularly
I Lessthan 1 year
I 1 to 2years
I 2to 5years
D 5to l0years
I Morethan l0years
Diet
On average, how many servings of fruits do you eat per day?
(One serving = 1 medium apple, banana, or orange; 1/2 cup chopped, cooked, or canned fruit; % cup
fruit juice)
DNone
DI
D2
D3
D4ormore
On average, how many servings of vegetables do you eat per day?
(One serving = 1/2 cup cooked or chopped raw, 1 cup raw leafy, 3/4 cup vegetable juice.)
DNone
DI
D2
D3
D4ormore
On average, how many servings of bread, cereal, rice, or pasta do you eat per day?
I None
I 1-3
D4-6
D7-9
I 10ormore
When you use grain and cereal products, which of the following do you emphasize?
I whole grain, high-fiber
64
I Mixture of whole grain and refined
I Refined, low-fiber
On average, how many servings of fish, poultry, lean meat, cooked dry beans, peanut butter, or nuts
do you eat per day?
(One serving = 2-3 ounces of meat, 1/2 cup cooked dry beans, 2 tablespoons peanut butter, or 1/3
cup of nuts.)
•None
DI
D2
D3
D4ormore
On average, how many servings of dairy products do you eat per day?
(One serving = 1 cup milk or yogurt,1.5 ounces natural cheese, 2 ounces processed cheese.)
DNone
DI
D2
D3
D4ormore
When you use dairy products, which do you emphasize?
DRegular
DLow-fat
DNonfat
How would you characterize your intake of fats and oils (e.g., regular salad dressings, butter or
margarine, mayonnaise, vegetable oils)?
I High
I Moderate
D Low
Body Data
How tall are you (without shoes)?
6
feet
3
inches
How much do you weigh (with minimal clothing and without shoes)?
What is the most you have ever weighed? 280
280
pounds
pounds
Which of the following are you c”7.re7G£/ry trying to do?
I Loseweight
EGainweight
Dstayaboutthesame
D Noneofthese
Psychological Health
How have you been feeling in general during the past month?
I ln excellentspirits
D lnverygood spirits
I l’vebeen upanddown inspiritsa lot
I ln lowspirits
I ln good spirits
I lnverylowspirits
During the past month, how much stress would you say that you have experienced?
I A lot
I Moderate
I Relatively little
I Almost none
ln the past year, how much effect has stress had on your health?
I A lot
I Some
I Hardlyanyor none
On average, how many hours of sleep do you get in a 24-hour period?
I Fewerthan 5 hours
I 5 or6 hours
I 7-9 hours
I Morethan 9 hours
Substance Use
Haveyou smoked at least 100 cigarettes in yourentire life?
DYes
I No
How would you describe your cigarette smoking habit?
I Never smoked
I Used to smoke-how many years has it been since you smoked?
years
4-6 _cigarettes/day
I Currently smoke-how many cigarettes do you smoke on average?
(continued)
Form2.3
(continued)
How many alcoholic drinks do you consume?
(A “drink” is a glass of wine, a wine cooler, a bottle or can of beer, a shot glass of liquor, or a mixed
drink.)
I None
I Lessthan 1 drink perweek
E 1 drinkperday
D2-3drinksperday
I 1-6 drinks perweek
DMorethan3drinksperday
Occupational Health
Lift boxes/furniture/appliances 4 or more hours per day.
These vary from a few pounds to over 50. I bend, stoop, and reach over head multiple times per day.
Please explain your main job duties:
After a day’s work, do you often have pain or stiffness that lasts for more than 3 hours?
I All thetime
I Mostofthetime
D Some ofthetime
. Rarelyornever
How often does your work entail repetitive pushing and pulling movements, or lifting while bending or
twisting, leading to back pain?
E All thetime
I Mostofthetime
I Some ofthetime
I Rarelyor never
I hereby state that, to the best of my knowledge, my answers to the preceding questions are complete
and correct.
12/1/2021
John Doe
Printed name of respondent
Signature of respondent
Date (mm/dd/yy)
Printed name ofparentofguardian
Signature ofparentorguardian
Date (mm/dd/yy)
12/1/2021
Lab Student
Printed name of witness
Signature of witness
Date (mm/dd/yy)
From G. Ha ff and C. Dumke, 2012, LczZ)orcz}ory owcz73″a//or exe7.cG.se pkys3.o/ogy (Champaign, IL: Human Kinetics). Adapted, by
permiss±on> from D.C . ENiema.n> 2003> Exercise testing arid DrescriDtion.. A health-related approach> Sth ed. (INow York.. MCGreNI-
Hill), 774. © The MCGraw-Hill Companies.
66
Form 2.4
Checklistforsigns and sym toms of Disease
Instructions: Ask your subject or client if he or she has any of the following conditions and risk factors.
If so, refer him or her to a physician to obtain a signed medical clearance prior to any exercise testing
or participation.
Doe
John
Last name
First name
Middle initial
Cardiovascular
Comments
Condition
Hypertension
Hypercholesterolemia
Total: 260, HDL: 34, LDL: 200
Heart murmur
Myocardial infarction
Fainting/dizziness
Claudication
Chest pain
Palpitation
lschemia
Tachycardia
Ankle edema
Stroke
Pulmonary
Asthma
Bronchitis
Emphysema
Nocturnal dyspnea
Recently diagnosed with Sleep apnea
Coughing up blood
Exercise-induced asthma
Breathlessness during or after mild exertion
Metabolic
Diabetes
Controlled by metformin. FBG: 98
Obesity
Glucose intolerance
MCArdle syndrome
Hypoglycemia
Thyroid disease
Cirrhosis
(continued)
67
Form 2.4
/co#J!.##ecz/
Musculoskeletal
Condition
Comments
Osteoporosis
Osteoarthritis
Low back pain Occurs on most days, does not take any pain medications
Prosthesis
Muscular atrophy
Swollen joints
Orthopedic pain
Artificial joint
Risk Factors
A client who has two or more of these factors should consult a physician for clearance to participate in
exercise testing.
I
I
Male olderthan 45 y
I
I
Female older than 55 y or who had hysterectomy or is postmenopausal
Smoking or quit smoking within past 6 months
Blood pressure >140/90 mmHg
Doesn’t know blood pressure
Blood cholesterol >200 mg/dl
Doesn’t know blood cholesterol
Close relative had heart attack before age 55 (father or brother) or age 65 (mother or
Physically inactive (does not engage in >30 min of physical activity more than 4 days/wk)
DD
Overweight by more than 20 lb (9 kg)
From G. Ha ff and C. Dumke, 2012, L&borafory 77?¢72#czJ/o7. cxe7.c3.se Pkys2.oJogy (Champaign, IL: Human Kinetics). Adapted,
by permission, from V. Heyward, 2010, Adz/cz73cedfi£7?ess c!ssess77?e73C cz7ed exerc3.se P7.escr?.PC8.o73, 6th ed. (Champaign, IL: Human
Kinetics), 320-321.
68
John Doe
2800 W Gore Blvd
999-999-9999
7/26/1966
0000001
John Doe
Patient directed glucose monitoring before and after exercise.
Dr. Richard Roe
999-999-0000
12/2/2021
Fitness Assessment
Client/Patient Name:
Date of Birth: 7/26/1966
Ethnicity:
RHR (bpm):
69
RBP (mmHg): 144 / 78
Today’s
Date: 12/1/2021
Gender: Male
John Doe
Age (y):
55
Referring Physician (if applicable):
Height (in):
75
Height (m):
1.905
Flexibility
Backsaver Sit-and-reach: 19 cm
Back Scratch Test: -2.4 cm
Muscular
Endurance/Strength
YMCA Bench Press: 23 Reps @ 80
kg
Predicted Bench Press 1 RM: 162
lbs.
Weight (lb): 280
Weight (kg): 127.01
Rank:
Rank:
40th percentile
Below Average
Rank: 80%
Predicted Relative 1RM: 0.58
Relative 1RM:
1.36
1 RM Leg Press: 380 lbs.
Cardiorespiratory Fitness
Stage/Minute
0/0
1/3
2/6
3/9
3/10
Speed Grade
0
0
1.7
10
2.5
12
3.4
14
3.4
14
HR
69
98
134
150
156
VO2(L/min) VO2(mL/min
1.09
1.68
2.74
2.9
9.8
15.5
21.5
22.7
VE
METs
VCO2
RER
RPE
30.9
46.2
60.5
68.6
4.6
7
10.2
10.2
0.91
1.25
3.2
3.42
0.83
0.74
1.17
1.18
13
15
17
19
Notes: Client requested to stop at 10 minutes due to severe fatigue.
QUESTION 3
1. Provide a paragraph or two discussing your interpretation of the data obtained for this client. You
should provide information that would help shape future exercise plans for this client based off of
their results and medical history. You should include enough information so that a third party (i.e.
physician) can comprehend the client’s status.
Open the pdf file to see the health history and answer the question.
Form 2.1
Informed consent Form
John Doe
have been informed that I will`
perform a series of tests in order to determine my physical fitness status as well as enhance my understanding of my own health and physical fitness status. I understand that I can voluntarily withdraw from
these tests at any time without any penalty. Additionally, I understand that I can ask questions about
the tests at any time and will have those questions answered to my satisfaction. In the event of any side
effects or injuries related to these tests, I understand that I may contact
at any time with my concerns.
Explanation of Tests:
I,
John Doe
Lab Student
understand that I will fill out a series
of questionnaires including a health history questionnaire and a PAR-Q in order to ensure my safety
during the testing process. I understand that if these questionnaires reveal that I am at significant risk
of an adverse event then no further tests will be conducted. I understand that if the questionnaires
reveal little risk to my safety, I will perform the remainder of the assessments. I will have my blood
pressure, body weight, and height assessed with methods typically used in a physician’s office. After
completing these assessments, I will have my body composition measured by Lab Student
which will evaluate how much fat and fat-free mass my body contains. I will then perform an assessment of my muscular strength and endurance, which will require me to lift weights for a number of
After completing this assessment,I will perform a graded
repetitions using a Free-Weight/Body Weight
exercise test on a Treadmill, Cycle, or Step in which the workload increases every few minutes until
exhaustion or until the test is terminated. I understand that this assessment will give insight into my
cardiorespiratory fitness.
Risks and Discomforts:
lt has been explained to me that during a graded exercise test, certain
physical changes can occur, including abnormal blood pressure responses, fainting, irregular heartbeat, and in some instances fatal heart attacks. In order to minimize these risks, the personnel conducting the test are trained to handle such adverse effects. Additionally, they are trained to recognize
#::i:a|tY%j’:#t,S:gnnds::8yw::;t::s:tT:nt:Sr:nogf:::jems:,ar::Sket:umne::r;:::da[shoatbteheenTn::::r:dmtehnatt°tfhe
assessment of muscular strength and endurance involves some risk of pulling or spraining a muscle and
that these risks will be minimized by employing a proper warm-up period and by means of technical
monitoring by the testing staff. I also understand that after the completion of the testing bouts, I may
experience some local muscle soreness that may last for 24 to 48 hours.
If muscle soreness does I occur, I understand that I can perform a series of stretches that have been
demonstrated to me by the testing staff. If these symptoms persist, I will report them to
Lab Student, other facility staff, and/or physician.
Benefits From Testing:
I understand that the results of these tests will give insight into my overall
physical health and wellness. Additionally,I have been informed that this information will reveal any
potential health hazards and can be used to better individualize my exercise program.
Inquiries:
I understand that if I have any questions, I can ask them of the testing staff. These questions will be answered to my satisfaction by the testing staff.
Confidentiality:
I understand that all of my personal health and physical fitness data will be kept
confidential.
(continued)
57
Form 2.1
(c.o#f!.73z{ec!/
I have read the information contained in this document and understand it. All questions pertaining to
the procedures that I am volunteering to undergo have been answered to my satisfaction. I understand
that I am free to decline answering any questions and to withdraw from this testing at any time without
penalty. Additionally,I have been informed that all of the information gathered about me and the tests
undertaken by me are confidential and will not be disclosed to anyone but me or others in my care or
used for exercise prescription without my written permission. Finally, I am aware of all risks associated
with this testing and voluntarily give my consent to participate in this testing.
12/1/2021
Signature of patient/client
12/1/2021
Signature of witness
Signature of supervisor
From G. Ha ff and C. Dumke, 2012, L¢bo7.cz!ory 7%a7?G/cz//or exe7.c3.se Pkys3.a/ogy (Champaign, IL: Human Kinetics). Adapted,
by permission, from D.C. Nieman, 2003, Exe7.c3.se Zesc€.7€g cz7€dp7.escr€.p£3.o7¢.. 4 feecz/£%-7.eJczlecz czPP7.oczcfe, 5th ed. (New York, NY:
MCGraw-Hill), 774. ©The MCGraw-Hill Companies.
58
Form 2.3
Health History Questionnaire
Contact Information
John
Doe
First name
Last name
55
7/26/1966
Date of birth (mm/dd/yy)
Middle initial
Sex: I Male I Female
Age
2800 W Gore Blvd
Lawton, Ok
73505
Home phone number
Street address
City, State
Zip code
Jane Doe
999 999
(–
999
IIIIIIE
999
9999
Emergency contact
Wife
9999
Relationship to emergency contact
Emergency contact number
Dr. Richard Roe
999 999
IIIIIIE-
Primary physician
Physician’s contact number
0000
Background
Please circle the highest school grade you have completed:
Primary:
1
2
3
4
Secondary:
9
10
11
12
College/postgrad:
13
Whatisyourmaritalstatus?
14
Dsingle
15
16
I Married
5
6
7
8
17
18
19
20+
Dwidowed
DDivorcedorseparated
What is your race or ethnic background?
D white, not of Hispanic origin
I Black, not of Hispanic origin
I American Indian/Alaskan native
I Asian
D pacific Islander
I Hispanic
What is your occupation?
DHea|th professional
DDisabled, unabletowork
Eservice
D¥raonf:gs::neaqucat°r’
Dskilled crafts
DOperator, fabricator, laborer
DHomemaker
DTechnical, sales, support
I Retired
I unemployed
I student
I other: Owner/Operator of a moving company
Symptoms or Signs Suggestive of Disease
Please place a check the appropriate box:
Yes
No
I
I
I
D
Have you experienced any unusual pain or discomfort in your chest, neck, jaw, arms, or
other areas that may be due to heart problems?
Have you experienced unusual fatigue and/or shortness of breath at rest, during usual
activities (e.g., climbing stairs, carrying groceries, walking briskly) or during mild or
moderate exercise?
I
D
Have you ever had any problems with dizziness or fainting?
I
I
When you stand up, do you have difficulty breathing?
I
I
Do you have difficulty breathing while sleeping?
I
D
Do your ankles swell (ankle edema)?
(continued)
61
Form 23
(continued)
Yes
No
D
I
Have your ever experienced an unusual or rapid heartbeat or fluttering of the heart?
I
I
Have you experienced severe pain in your legs while walking?
I
I
Have you ever been told by a doctor thatyou have a heart murmur?
Chronic Disease Risk Factors
Do you knowyourblood pressure?
I =Yes:
Doyou knowyourcholesterol levels?
I =Yes:
260
Doyou knowyourfasting glucose levels?
I =Yes:
/_systolic/diastolic
I = No
200
total cholesterol;_HDL;_LDL
34
98 mg/dl
I = No
I = No
Please place a check in the appropriate box:
Yes
No
I
D
I
I
lfyou are a female, have you experienced premature menopause and are not on
estrogen replacement therapy?
I
I
Has your father or brother had a heart attack or died suddenly from heart disease
before the age of 55?
I
I
Has your mother or sister had a heart attack or died suddenly from heart disease
before the age of 65?
I
I
Has anyone in your family died before the age of40 (excluding accidental death)?
I
I
Are you a current cigarette smoker?
I
I
Has a doctor told you that you have high blood pressure (more than 130/80)?
D
I
Areyou a male overthe age of45 ora female overthe age of55?
Are you on medication to control high blood pressure?
I
I
Has a doctor evertold you that you have high cholesterol?
I
D
ls your serum cholesterol greaterthan 200 mg/dl?
I
D
Do you have diabetes mellitus?
D
I
Are you physically inactive or sedentary (i.e., do you perform little physical activity on
the I.ob or during leisure time)?
I
I
I
D
During the past year, have you experienced levels of stress, strain, and pressure that
might affect your health?
Do you eat foods that are high in fat and cholesterol, such as fatty meats, cheese, fried
food, butter, whole milk, or eggs on a daily basis?
I
I
Do you tend to avoid foods that are high in fiber, such as whole-grain breads and
cereals, fresh fruits, and vegetables?
I
E
Do you weigh 30 pounds more than you should?
I
I
Do you average more than two alcoholic beverages a day?
Medical History
Please check all conditions that you or your family have had or now have.
Your
You
62
Your
family
You
family
DD
Coronary heart disease, heart
attack, coronary artery surgery
I
I
Peripheral vascular disease
DD
Angina
I
I
Phlebitis or emboli
Your
Your
You
family
You
family
I
I
Other heart problems (Specify:
DD
Major injury to foot, leg, knee,
hip, or shoulder
I
I
Lung cancer
I
I
Major inj.ury to back or neck
I
I
Breast cancer
I
I
Stomach or duodenal ulcer
I
I
Prostate cancer
I
I
Rectal growth or bleeding
I
I
Colorectal cancer (bowel cancer)
I
I
Cataracts
D
I
Skin cancer
I
I
Glaucoma
I
I
Other cancer (Specify:
I
I
Hearing loss
)D
I
Depression
D
I
High anxiety, phobia
D
D
I
I
I
Stro ke
I
I
Chronic obstructive pulmonary
disease (emphysema)
I
Pneumonia
I
I
Asthma
I
I
Bronchitis
I
I
Diabetes mellitus
I
I
Thyroid problems
I
.
Kidney disease
I
I
Liver disease (cirrhosis of the
liver)
D
.
Hepatitis (A, B, C, D, or E)
D
I
Gallstone/gallbladder disease
D
I
Osteoporosis
I
I
Arthritis
I
I
Gout
I
I
Anemia (low iron)
I
I
Bone fracture
I
I
I
D
I
B
I
Substance abuse problems (e.g.,
alcohol, drugs)
I
Eating disorders (anorexia,
bulimia)
I
Problems with menstruation
I
Hysterectomy
I
Sleeping problems
I
Allergies
I
H IV/AIDS
I
Any other problems (please
be specific and include information on any recent illnesses,
hospitalizations, or surgical
procedures):
Low-back pain on most days at work.
Medications
Please check any of the following types of medication that you currently take regularly. Also give the
name of the medication.
Type of medication
Name of medication
I Heart medicine
I Blood pressure medicine
I Blood cholesterol medicine
I Hormones
I Birth control pills
I Medicine for breathing or lungs
B Insulin
I Other medicines for diabetes
Metformin
(continued)
63
Form2.3
(continued)
I Arthritis medicine
I Medicine for depression
I Medicine for anxiety
I Thyroid medicine
I Medicine for ulcers
I Painkiller medicine
I Allergy medicine
I HIV/AIDS medicine
I Hepatitis medicine
Nandrolone (for low testosterone)
I Other (please specify)
Physical Fitness, Physical Activity, and Exercise
ln general, compared with other persons your age, rate how physically fit you are:
1
2
3
4
5
6
7
8
9
10
D.DDDDDDDD
Not at all fit
Somewhat fit
Extremely fit
Outside of your normal work or daily responsibilities, how often do you engage in exercise that at
least moderately increases your breathing and heart rate, and makes you sweat, for at least 20 minutes
(e.g., brisk walking, cycling, swimming, aerobic dance, stair climbing, rowing, basketball, racquetball,
vigorous yardwork).
D5ormoretimesperweek
D3or4timesperweek
I Lessthan once aweek
. Seldom or never
I 1 or2timesperweek
How much hard physical work is required on your job?
I A great deal
I A moderate amount
I A little
I None
How long have you exercised or played sports regularly?
D I do notexercise regularly
I Lessthan 1 year
I 1 to 2years
I 2to 5years
D 5to l0years
I Morethan l0years
Diet
On average, how many servings of fruits do you eat per day?
(One serving = 1 medium apple, banana, or orange; 1/2 cup chopped, cooked, or canned fruit; % cup
fruit juice)
DNone
DI
D2
D3
D4ormore
On average, how many servings of vegetables do you eat per day?
(One serving = 1/2 cup cooked or chopped raw, 1 cup raw leafy, 3/4 cup vegetable juice.)
DNone
DI
D2
D3
D4ormore
On average, how many servings of bread, cereal, rice, or pasta do you eat per day?
I None
I 1-3
D4-6
D7-9
I 10ormore
When you use grain and cereal products, which of the following do you emphasize?
I whole grain, high-fiber
64
I Mixture of whole grain and refined
I Refined, low-fiber
On average, how many servings of fish, poultry, lean meat, cooked dry beans, peanut butter, or nuts
do you eat per day?
(One serving = 2-3 ounces of meat, 1/2 cup cooked dry beans, 2 tablespoons peanut butter, or 1/3
cup of nuts.)
•None
DI
D2
D3
D4ormore
On average, how many servings of dairy products do you eat per day?
(One serving = 1 cup milk or yogurt,1.5 ounces natural cheese, 2 ounces processed cheese.)
DNone
DI
D2
D3
D4ormore
When you use dairy products, which do you emphasize?
DRegular
DLow-fat
DNonfat
How would you characterize your intake of fats and oils (e.g., regular salad dressings, butter or
margarine, mayonnaise, vegetable oils)?
I High
I Moderate
D Low
Body Data
How tall are you (without shoes)?
6
feet
3
inches
How much do you weigh (with minimal clothing and without shoes)?
What is the most you have ever weighed? 280
280
pounds
pounds
Which of the following are you c”7.re7G£/ry trying to do?
I Loseweight
EGainweight
Dstayaboutthesame
D Noneofthese
Psychological Health
How have you been feeling in general during the past month?
I ln excellentspirits
D lnverygood spirits
I l’vebeen upanddown inspiritsa lot
I ln lowspirits
I ln good spirits
I lnverylowspirits
During the past month, how much stress would you say that you have experienced?
I A lot
I Moderate
I Relatively little
I Almost none
ln the past year, how much effect has stress had on your health?
I A lot
I Some
I Hardlyanyor none
On average, how many hours of sleep do you get in a 24-hour period?
I Fewerthan 5 hours
I 5 or6 hours
I 7-9 hours
I Morethan 9 hours
Substance Use
Haveyou smoked at least 100 cigarettes in yourentire life?
DYes
I No
How would you describe your cigarette smoking habit?
I Never smoked
I Used to smoke-how many years has it been since you smoked?
years
4-6 _cigarettes/day
I Currently smoke-how many cigarettes do you smoke on average?
(continued)
Form2.3
(continued)
How many alcoholic drinks do you consume?
(A “drink” is a glass of wine, a wine cooler, a bottle or can of beer, a shot glass of liquor, or a mixed
drink.)
I None
I Lessthan 1 drink perweek
E 1 drinkperday
D2-3drinksperday
I 1-6 drinks perweek
DMorethan3drinksperday
Occupational Health
Lift boxes/furniture/appliances 4 or more hours per day.
These vary from a few pounds to over 50. I bend, stoop, and reach over head multiple times per day.
Please explain your main job duties:
After a day’s work, do you often have pain or stiffness that lasts for more than 3 hours?
I All thetime
I Mostofthetime
D Some ofthetime
. Rarelyornever
How often does your work entail repetitive pushing and pulling movements, or lifting while bending or
twisting, leading to back pain?
E All thetime
I Mostofthetime
I Some ofthetime
I Rarelyor never
I hereby state that, to the best of my knowledge, my answers to the preceding questions are complete
and correct.
12/1/2021
John Doe
Printed name of respondent
Signature of respondent
Date (mm/dd/yy)
Printed name ofparentofguardian
Signature ofparentorguardian
Date (mm/dd/yy)
12/1/2021
Lab Student
Printed name of witness
Signature of witness
Date (mm/dd/yy)
From G. Ha ff and C. Dumke, 2012, LczZ)orcz}ory owcz73″a//or exe7.cG.se pkys3.o/ogy (Champaign, IL: Human Kinetics). Adapted, by
permiss±on> from D.C . ENiema.n> 2003> Exercise testing arid DrescriDtion.. A health-related approach> Sth ed. (INow York.. MCGreNI-
Hill), 774. © The MCGraw-Hill Companies.
66
Form 2.4
Checklistforsigns and sym toms of Disease
Instructions: Ask your subject or client if he or she has any of the following conditions and risk factors.
If so, refer him or her to a physician to obtain a signed medical clearance prior to any exercise testing
or participation.
Doe
John
Last name
First name
Middle initial
Cardiovascular
Comments
Condition
Hypertension
Hypercholesterolemia
Total: 260, HDL: 34, LDL: 200
Heart murmur
Myocardial infarction
Fainting/dizziness
Claudication
Chest pain
Palpitation
lschemia
Tachycardia
Ankle edema
Stroke
Pulmonary
Asthma
Bronchitis
Emphysema
Nocturnal dyspnea
Recently diagnosed with Sleep apnea
Coughing up blood
Exercise-induced asthma
Breathlessness during or after mild exertion
Metabolic
Diabetes
Controlled by metformin. FBG: 98
Obesity
Glucose intolerance
MCArdle syndrome
Hypoglycemia
Thyroid disease
Cirrhosis
(continued)
67
Form 2.4
/co#J!.##ecz/
Musculoskeletal
Condition
Comments
Osteoporosis
Osteoarthritis
Low back pain Occurs on most days, does not take any pain medications
Prosthesis
Muscular atrophy
Swollen joints
Orthopedic pain
Artificial joint
Risk Factors
A client who has two or more of these factors should consult a physician for clearance to participate in
exercise testing.
I
I
Male olderthan 45 y
I
I
Female older than 55 y or who had hysterectomy or is postmenopausal
Smoking or quit smoking within past 6 months
Blood pressure >140/90 mmHg
Doesn’t know blood pressure
Blood cholesterol >200 mg/dl
Doesn’t know blood cholesterol
Close relative had heart attack before age 55 (father or brother) or age 65 (mother or
Physically inactive (does not engage in >30 min of physical activity more than 4 days/wk)
DD
Overweight by more than 20 lb (9 kg)
From G. Ha ff and C. Dumke, 2012, L&borafory 77?¢72#czJ/o7. cxe7.c3.se Pkys2.oJogy (Champaign, IL: Human Kinetics). Adapted,
by permission, from V. Heyward, 2010, Adz/cz73cedfi£7?ess c!ssess77?e73C cz7ed exerc3.se P7.escr?.PC8.o73, 6th ed. (Champaign, IL: Human
Kinetics), 320-321.
68
John Doe
2800 W Gore Blvd
999-999-9999
7/26/1966
0000001
John Doe
Patient directed glucose monitoring before and after exercise.
Dr. Richard Roe
999-999-0000
12/2/2021
Fitness Assessment
Client/Patient Name:
Date of Birth: 7/26/1966
Ethnicity:
RHR (bpm):
69
RBP (mmHg): 144 / 78
Today’s
Date: 12/1/2021
Gender: Male
John Doe
Age (y):
55
Referring Physician (if applicable):
Height (in):
75
Height (m):
1.905
Flexibility
Backsaver Sit-and-reach: 19 cm
Back Scratch Test: -2.4 cm
Muscular
Endurance/Strength
YMCA Bench Press: 23 Reps @ 80
kg
Predicted Bench Press 1 RM: 162
lbs.
Weight (lb): 280
Weight (kg): 127.01
Rank:
Rank:
40th percentile
Below Average
Rank: 80%
Predicted Relative 1RM: 0.58
Relative 1RM:
1.36
1 RM Leg Press: 380 lbs.
Cardiorespiratory Fitness
Stage/Minute
0/0
1/3
2/6
3/9
3/10
Speed Grade
0
0
1.7
10
2.5
12
3.4
14
3.4
14
HR
69
98
134
150
156
VO2(L/min) VO2(mL/min
1.09
1.68
2.74
2.9
9.8
15.5
21.5
22.7
VE
METs
VCO2
RER
RPE
30.9
46.2
60.5
68.6
4.6
7
10.2
10.2
0.91
1.25
3.2
3.42
0.83
0.74
1.17
1.18
13
15
17
19
Notes: Client requested to stop at 10 minutes due to severe fatigue.
QUESTION 4
1. Provide a paragraph or two discussing a potential exercise plan for this client. The information
you provide should include pertinent short and long term goals, interventions (exercise), and
future directions. You should include enough information so that a third party (i.e. physician) can
comprehend the client’s status.
Open the pdf file to see the health history and answer the question.
Form 2.1
Informed consent Form
John Doe
have been informed that I will`
perform a series of tests in order to determine my physical fitness status as well as enhance my understanding of my own health and physical fitness status. I understand that I can voluntarily withdraw from
these tests at any time without any penalty. Additionally, I understand that I can ask questions about
the tests at any time and will have those questions answered to my satisfaction. In the event of any side
effects or injuries related to these tests, I understand that I may contact
at any time with my concerns.
Explanation of Tests:
I,
John Doe
Lab Student
understand that I will fill out a series
of questionnaires including a health history questionnaire and a PAR-Q in order to ensure my safety
during the testing process. I understand that if these questionnaires reveal that I am at significant risk
of an adverse event then no further tests will be conducted. I understand that if the questionnaires
reveal little risk to my safety, I will perform the remainder of the assessments. I will have my blood
pressure, body weight, and height assessed with methods typically used in a physician’s office. After
completing these assessments, I will have my body composition measured by Lab Student
which will evaluate how much fat and fat-free mass my body contains. I will then perform an assessment of my muscular strength and endurance, which will require me to lift weights for a number of
After completing this assessment,I will perform a graded
repetitions using a Free-Weight/Body Weight
exercise test on a Treadmill, Cycle, or Step in which the workload increases every few minutes until
exhaustion or until the test is terminated. I understand that this assessment will give insight into my
cardiorespiratory fitness.
Risks and Discomforts:
lt has been explained to me that during a graded exercise test, certain
physical changes can occur, including abnormal blood pressure responses, fainting, irregular heartbeat, and in some instances fatal heart attacks. In order to minimize these risks, the personnel conducting the test are trained to handle such adverse effects. Additionally, they are trained to recognize
#::i:a|tY%j’:#t,S:gnnds::8yw::;t::s:tT:nt:Sr:nogf:::jems:,ar::Sket:umne::r;:::da[shoatbteheenTn::::r:dmtehnatt°tfhe
assessment of muscular strength and endurance involves some risk of pulling or spraining a muscle and
that these risks will be minimized by employing a proper warm-up period and by means of technical
monitoring by the testing staff. I also understand that after the completion of the testing bouts, I may
experience some local muscle soreness that may last for 24 to 48 hours.
If muscle soreness does I occur, I understand that I can perform a series of stretches that have been
demonstrated to me by the testing staff. If these symptoms persist, I will report them to
Lab Student, other facility staff, and/or physician.
Benefits From Testing:
I understand that the results of these tests will give insight into my overall
physical health and wellness. Additionally,I have been informed that this information will reveal any
potential health hazards and can be used to better individualize my exercise program.
Inquiries:
I understand that if I have any questions, I can ask them of the testing staff. These questions will be answered to my satisfaction by the testing staff.
Confidentiality:
I understand that all of my personal health and physical fitness data will be kept
confidential.
(continued)
57
Form 2.1
(c.o#f!.73z{ec!/
I have read the information contained in this document and understand it. All questions pertaining to
the procedures that I am volunteering to undergo have been answered to my satisfaction. I understand
that I am free to decline answering any questions and to withdraw from this testing at any time without
penalty. Additionally,I have been informed that all of the information gathered about me and the tests
undertaken by me are confidential and will not be disclosed to anyone but me or others in my care or
used for exercise prescription without my written permission. Finally, I am aware of all risks associated
with this testing and voluntarily give my consent to participate in this testing.
12/1/2021
Signature of patient/client
12/1/2021
Signature of witness
Signature of supervisor
From G. Ha ff and C. Dumke, 2012, L¢bo7.cz!ory 7%a7?G/cz//or exe7.c3.se Pkys3.a/ogy (Champaign, IL: Human Kinetics). Adapted,
by permission, from D.C. Nieman, 2003, Exe7.c3.se Zesc€.7€g cz7€dp7.escr€.p£3.o7¢.. 4 feecz/£%-7.eJczlecz czPP7.oczcfe, 5th ed. (New York, NY:
MCGraw-Hill), 774. ©The MCGraw-Hill Companies.
58
Form 2.3
Health History Questionnaire
Contact Information
John
Doe
First name
Last name
55
7/26/1966
Date of birth (mm/dd/yy)
Middle initial
Sex: I Male I Female
Age
2800 W Gore Blvd
Lawton, Ok
73505
Home phone number
Street address
City, State
Zip code
Jane Doe
999 999
(–
999
IIIIIIE
999
9999
Emergency contact
Wife
9999
Relationship to emergency contact
Emergency contact number
Dr. Richard Roe
999 999
IIIIIIE-
Primary physician
Physician’s contact number
0000
Background
Please circle the highest school grade you have completed:
Primary:
1
2
3
4
Secondary:
9
10
11
12
College/postgrad:
13
Whatisyourmaritalstatus?
14
Dsingle
15
16
I Married
5
6
7
8
17
18
19
20+
Dwidowed
DDivorcedorseparated
What is your race or ethnic background?
D white, not of Hispanic origin
I Black, not of Hispanic origin
I American Indian/Alaskan native
I Asian
D pacific Islander
I Hispanic
What is your occupation?
DHea|th professional
DDisabled, unabletowork
Eservice
D¥raonf:gs::neaqucat°r’
Dskilled crafts
DOperator, fabricator, laborer
DHomemaker
DTechnical, sales, support
I Retired
I unemployed
I student
I other: Owner/Operator of a moving company
Symptoms or Signs Suggestive of Disease
Please place a check the appropriate box:
Yes
No
I
I
I
D
Have you experienced any unusual pain or discomfort in your chest, neck, jaw, arms, or
other areas that may be due to heart problems?
Have you experienced unusual fatigue and/or shortness of breath at rest, during usual
activities (e.g., climbing stairs, carrying groceries, walking briskly) or during mild or
moderate exercise?
I
D
Have you ever had any problems with dizziness or fainting?
I
I
When you stand up, do you have difficulty breathing?
I
I
Do you have difficulty breathing while sleeping?
I
D
Do your ankles swell (ankle edema)?
(continued)
61
Form 23
(continued)
Yes
No
D
I
Have your ever experienced an unusual or rapid heartbeat or fluttering of the heart?
I
I
Have you experienced severe pain in your legs while walking?
I
I
Have you ever been told by a doctor thatyou have a heart murmur?
Chronic Disease Risk Factors
Do you knowyourblood pressure?
I =Yes:
Doyou knowyourcholesterol levels?
I =Yes:
260
Doyou knowyourfasting glucose levels?
I =Yes:
/_systolic/diastolic
I = No
200
total cholesterol;_HDL;_LDL
34
98 mg/dl
I = No
I = No
Please place a check in the appropriate box:
Yes
No
I
D
I
I
lfyou are a female, have you experienced premature menopause and are not on
estrogen replacement therapy?
I
I
Has your father or brother had a heart attack or died suddenly from heart disease
before the age of 55?
I
I
Has your mother or sister had a heart attack or died suddenly from heart disease
before the age of 65?
I
I
Has anyone in your family died before the age of40 (excluding accidental death)?
I
I
Are you a current cigarette smoker?
I
I
Has a doctor told you that you have high blood pressure (more than 130/80)?
D
I
Areyou a male overthe age of45 ora female overthe age of55?
Are you on medication to control high blood pressure?
I
I
Has a doctor evertold you that you have high cholesterol?
I
D
ls your serum cholesterol greaterthan 200 mg/dl?
I
D
Do you have diabetes mellitus?
D
I
Are you physically inactive or sedentary (i.e., do you perform little physical activity on
the I.ob or during leisure time)?
I
I
I
D
During the past year, have you experienced levels of stress, strain, and pressure that
might affect your health?
Do you eat foods that are high in fat and cholesterol, such as fatty meats, cheese, fried
food, butter, whole milk, or eggs on a daily basis?
I
I
Do you tend to avoid foods that are high in fiber, such as whole-grain breads and
cereals, fresh fruits, and vegetables?
I
E
Do you weigh 30 pounds more than you should?
I
I
Do you average more than two alcoholic beverages a day?
Medical History
Please check all conditions that you or your family have had or now have.
Your
You
62
Your
family
You
family
DD
Coronary heart disease, heart
attack, coronary artery surgery
I
I
Peripheral vascular disease
DD
Angina
I
I
Phlebitis or emboli
Your
Your
You
family
You
family
I
I
Other heart problems (Specify:
DD
Major injury to foot, leg, knee,
hip, or shoulder
I
I
Lung cancer
I
I
Major inj.ury to back or neck
I
I
Breast cancer
I
I
Stomach or duodenal ulcer
I
I
Prostate cancer
I
I
Rectal growth or bleeding
I
I
Colorectal cancer (bowel cancer)
I
I
Cataracts
D
I
Skin cancer
I
I
Glaucoma
I
I
Other cancer (Specify:
I
I
Hearing loss
)D
I
Depression
D
I
High anxiety, phobia
D
D
I
I
I
Stro ke
I
I
Chronic obstructive pulmonary
disease (emphysema)
I
Pneumonia
I
I
Asthma
I
I
Bronchitis
I
I
Diabetes mellitus
I
I
Thyroid problems
I
.
Kidney disease
I
I
Liver disease (cirrhosis of the
liver)
D
.
Hepatitis (A, B, C, D, or E)
D
I
Gallstone/gallbladder disease
D
I
Osteoporosis
I
I
Arthritis
I
I
Gout
I
I
Anemia (low iron)
I
I
Bone fracture
I
I
I
D
I
B
I
Substance abuse problems (e.g.,
alcohol, drugs)
I
Eating disorders (anorexia,
bulimia)
I
Problems with menstruation
I
Hysterectomy
I
Sleeping problems
I
Allergies
I
H IV/AIDS
I
Any other problems (please
be specific and include information on any recent illnesses,
hospitalizations, or surgical
procedures):
Low-back pain on most days at work.
Medications
Please check any of the following types of medication that you currently take regularly. Also give the
name of the medication.
Type of medication
Name of medication
I Heart medicine
I Blood pressure medicine
I Blood cholesterol medicine
I Hormones
I Birth control pills
I Medicine for breathing or lungs
B Insulin
I Other medicines for diabetes
Metformin
(continued)
63
Form2.3
(continued)
I Arthritis medicine
I Medicine for depression
I Medicine for anxiety
I Thyroid medicine
I Medicine for ulcers
I Painkiller medicine
I Allergy medicine
I HIV/AIDS medicine
I Hepatitis medicine
Nandrolone (for low testosterone)
I Other (please specify)
Physical Fitness, Physical Activity, and Exercise
ln general, compared with other persons your age, rate how physically fit you are:
1
2
3
4
5
6
7
8
9
10
D.DDDDDDDD
Not at all fit
Somewhat fit
Extremely fit
Outside of your normal work or daily responsibilities, how often do you engage in exercise that at
least moderately increases your breathing and heart rate, and makes you sweat, for at least 20 minutes
(e.g., brisk walking, cycling, swimming, aerobic dance, stair climbing, rowing, basketball, racquetball,
vigorous yardwork).
D5ormoretimesperweek
D3or4timesperweek
I Lessthan once aweek
. Seldom or never
I 1 or2timesperweek
How much hard physical work is required on your job?
I A great deal
I A moderate amount
I A little
I None
How long have you exercised or played sports regularly?
D I do notexercise regularly
I Lessthan 1 year
I 1 to 2years
I 2to 5years
D 5to l0years
I Morethan l0years
Diet
On average, how many servings of fruits do you eat per day?
(One serving = 1 medium apple, banana, or orange; 1/2 cup chopped, cooked, or canned fruit; % cup
fruit juice)
DNone
DI
D2
D3
D4ormore
On average, how many servings of vegetables do you eat per day?
(One serving = 1/2 cup cooked or chopped raw, 1 cup raw leafy, 3/4 cup vegetable juice.)
DNone
DI
D2
D3
D4ormore
On average, how many servings of bread, cereal, rice, or pasta do you eat per day?
I None
I 1-3
D4-6
D7-9
I 10ormore
When you use grain and cereal products, which of the following do you emphasize?
I whole grain, high-fiber
64
I Mixture of whole grain and refined
I Refined, low-fiber
On average, how many servings of fish, poultry, lean meat, cooked dry beans, peanut butter, or nuts
do you eat per day?
(One serving = 2-3 ounces of meat, 1/2 cup cooked dry beans, 2 tablespoons peanut butter, or 1/3
cup of nuts.)
•None
DI
D2
D3
D4ormore
On average, how many servings of dairy products do you eat per day?
(One serving = 1 cup milk or yogurt,1.5 ounces natural cheese, 2 ounces processed cheese.)
DNone
DI
D2
D3
D4ormore
When you use dairy products, which do you emphasize?
DRegular
DLow-fat
DNonfat
How would you characterize your intake of fats and oils (e.g., regular salad dressings, butter or
margarine, mayonnaise, vegetable oils)?
I High
I Moderate
D Low
Body Data
How tall are you (without shoes)?
6
feet
3
inches
How much do you weigh (with minimal clothing and without shoes)?
What is the most you have ever weighed? 280
280
pounds
pounds
Which of the following are you c”7.re7G£/ry trying to do?
I Loseweight
EGainweight
Dstayaboutthesame
D Noneofthese
Psychological Health
How have you been feeling in general during the past month?
I ln excellentspirits
D lnverygood spirits
I l’vebeen upanddown inspiritsa lot
I ln lowspirits
I ln good spirits
I lnverylowspirits
During the past month, how much stress would you say that you have experienced?
I A lot
I Moderate
I Relatively little
I Almost none
ln the past year, how much effect has stress had on your health?
I A lot
I Some
I Hardlyanyor none
On average, how many hours of sleep do you get in a 24-hour period?
I Fewerthan 5 hours
I 5 or6 hours
I 7-9 hours
I Morethan 9 hours
Substance Use
Haveyou smoked at least 100 cigarettes in yourentire life?
DYes
I No
How would you describe your cigarette smoking habit?
I Never smoked
I Used to smoke-how many years has it been since you smoked?
years
4-6 _cigarettes/day
I Currently smoke-how many cigarettes do you smoke on average?
(continued)
Form2.3
(continued)
How many alcoholic drinks do you consume?
(A “drink” is a glass of wine, a wine cooler, a bottle or can of beer, a shot glass of liquor, or a mixed
drink.)
I None
I Lessthan 1 drink perweek
E 1 drinkperday
D2-3drinksperday
I 1-6 drinks perweek
DMorethan3drinksperday
Occupational Health
Lift boxes/furniture/appliances 4 or more hours per day.
These vary from a few pounds to over 50. I bend, stoop, and reach over head multiple times per day.
Please explain your main job duties:
After a day’s work, do you often have pain or stiffness that lasts for more than 3 hours?
I All thetime
I Mostofthetime
D Some ofthetime
. Rarelyornever
How often does your work entail repetitive pushing and pulling movements, or lifting while bending or
twisting, leading to back pain?
E All thetime
I Mostofthetime
I Some ofthetime
I Rarelyor never
I hereby state that, to the best of my knowledge, my answers to the preceding questions are complete
and correct.
12/1/2021
John Doe
Printed name of respondent
Signature of respondent
Date (mm/dd/yy)
Printed name ofparentofguardian
Signature ofparentorguardian
Date (mm/dd/yy)
12/1/2021
Lab Student
Printed name of witness
Signature of witness
Date (mm/dd/yy)
From G. Ha ff and C. Dumke, 2012, LczZ)orcz}ory owcz73″a//or exe7.cG.se pkys3.o/ogy (Champaign, IL: Human Kinetics). Adapted, by
permiss±on> from D.C . ENiema.n> 2003> Exercise testing arid DrescriDtion.. A health-related approach> Sth ed. (INow York.. MCGreNI-
Hill), 774. © The MCGraw-Hill Companies.
66
Form 2.4
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