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Pre-Exercise Testing Screening Questions

First Name

Last Name

Email

Date of Birth

Cardiovascular & Pulmonary

Have you ever been told you have heart disease, a heart murmur, or an abnormal heart rhythm?

Have you ever had chest pain, pressure, or tightness with exertion?

Do you ever experience shortness of breath at rest, or with mild exertion?

Have you ever fainted, become very dizzy, or lost consciousness during exercise?

Do you have high blood pressure, high cholesterol, or other known cardiovascular risk factors?

Have you ever been told you have a lung disease (such as COPD or asthma) that limits exercise?

Neurologic & Musculoskeletal

Do you have any current or chronic musculoskeletal injuries that limit your ability to exercise (e.g., knee, hip, or back pain)?

Do you have a neurologic condition that affects balance, strength, or coordination?

Metabolic & General Health

Do you have diabetes or problems with blood sugar regulation?

Do you ever feel lightheaded, shaky, or faint during physical activity?

Are you currently pregnant?

Recent Health Events

Have you had surgery, hospitalization, or a major illness in the past 6 months?

Are you currently taking medications that may affect exercise response (e.g., beta blockers, anti-arrhythmics, insulin)?

Exercise Tolerance

Do you participate in regular exercise currently? If yes, what type and how often?

Is there any reason, not already mentioned, why you should not participate in an exercise test today?

Purpose of Testing

You are being asked to participate in exercise testing (which may include VO₂ max testing, body composition assessment, fitness assessments, or other physical performance testing). The purpose of these assessments is to evaluate your current level of fitness and health to guide recommendations for your wellness plan.

Risks

I understand that participation in exercise testing carries potential risks, including but not limited to:

- Abnormal blood pressure or heart rhythm

- Dizziness, fainting, or loss of consciousness

- Musculoskeletal injury (such as strains or sprains)

- Rare but serious events such as heart attack, stroke, or sudden deat

I understand that while precautions will be taken, Paragon Total Wellness and its staff cannot guarantee that complications will not occur.

Responsibilities

I agree to:

- Provide complete and accurate medical information prior to testing

- Inform the testing staff immediately if I experience pain, shortness of breath, dizziness, or any unusual symptoms during testing

-Follow all instructions provided by staff for my safety

Confidentiality

All information obtained during testing will be kept confidential and included as part of my medical record with Paragon Total Wellness. Results may be used for treatment planning and progress monitoring.

Acknowledgment of Voluntary Participation

I understand that participation in exercise testing is voluntary and that I may stop testing at any time. I understand the nature of the testing procedures and acknowledge the risks involved.

Release of Liability

In consideration of being allowed to participate in exercise testing, I hereby release, discharge, and hold harmless Paragon Total Wellness, its employees, agents, and representatives from any and all liability, claims, or causes of action arising out of my participation in exercise testing, except in cases of gross negligence or willful misconduct.

Participate Signature

By signing below, I confirm that I have read and understood this document, that all of my questions have been answered, and that I voluntarily agree to participate.

Signature of Participate

Signature