Risk Assessment Questionnaire
SSN: Member Name: Risk Assessment Date:
Coronary Artery Disease Risk Factors
Are you a male greater than 40 years old or a female greater than 50 years old and do not participate in a consistent aerobic exercise activity three to five times weekly?
Has your mother or sister died without any explanation (sudden death) or suffered from a heart attack before the age of 55
Has your father or brother died without any explanation (sudden death) or suffered from a heart attack before the age of 45?
Are you a current tobacco user?
Do you have high blood pressure or are you on blood pressure medication?
Has a doctor ever told you that you have high cholesterol or are you on cholesterol medication?
Do you have diabetes?
Are you sedentary (don't exercise at least three to five times per week for at least 30 minutes)?
Do you have any personal history of metabolic disease (thyroid, renal, liver)?
Have you ever passed out during exercise?
Have you ever been told you have a heart murmur?
Have you ever been dizzy or lightheaded during or after exercise?
Do you have known cardiac (heart) disease?
Has a health care provider ever denied or restricted your participation in sports?
Do you tire more quickly than your friends do during exercise?
Signs & Symptoms
Do you feel pain in your chest, neck, jaw, or arms when doing physical activity?
Do you experience any shortness of breath with moderate continuous exercise?
In the last month, have you felt chest pain at rest?
Have you had a severe viral infection such as myocarditis or mononucleosis within the past month?
Have you experienced episodes of rapid beating or fluttering of the heart?
Have you unintentionally lost or gained more than 10 percent of your body weight since the last PFA?
Do you suffer from lower leg swelling of both legs?
Do you have difficulty breathing or have sudden breathing problems at night?
Do you have a bone, joint, or muscle problem that may prevent you from doing physical activity of any kind?
Signature: Date:

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