2X2

FITNESS ASSESSMENT FORM PICTURE

Personal Information GOAL: _______________________

Last Name: First: Middle:
Age: Sex: Birth date:
Contact #: Email Add.: Class Schedule:
Resting BP: _________________ Resting HR: __________________ Target Heart Rate: ____________________

Table 1.1 `PHILIPPINE PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

(Bonoan, Bernardo, 2006)
Please read the questions carefully and answer each one honestly.
Basahin ng mabuti ang mga tanong at sagutin ng buong tapat.

YES NO
Has your doctor ever diagnosed you to have a heart condition and that you should only do
physical activity recommended by a doctor?
(Sinabihan ka nab a ng doctor mo na ikaw ay makaramdam sa puso at ang dapat mo lang
gawing pisikal ay ang rekomendado ng doctor?)
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
(Kasalukuyan ka bang umiinom ng gamut na inirineseta ng doctor mo para sa mattas na
presyon ng dugo o karamdaman sa puso?)

Do you experience pain or discomfort in the chest, neck and jaw area during mild physical
activity or at rest?
(Nakaramdam kaba ng sakit o karamdaman sa dibdib, leeg o gawing panghabang
gumagawa ng malumanay na gawaing pisikal o kaya nagpapahinga?).
Do you experience shortness of breath with mild physical exertion?
(Nakakaramdam ka ban g kahirapan sa paghinga habang gumawa ng malumanay na
gawaing pisikal)

Do you get tired frequently even when not doing physical activity or are you frequently
drowsy?
(Madalas ka bang napapagod maski maski na walang ginagawang pisikal o madalas ka
bang nananamlay?)
Have you lost weight recently with or without feelings of extreme hunger?

(Nmaayat o nawlan ka ban g timbang ng subrang bilis kamakailan, o ng hindi

nakaramdam ng matinding gutom?
Do you have a bone or joint pain that increase with movement? Is there a sudden increase
in pain when bending or touching the joint?
(Ikaw ba ay may nararamdaman na sakit sabuto o kasu-kasuan na lumalalapag gumalaw?
May biglang pagtindi ng sakit ba kung binabaluktot o hinahawakan ang kasu-kasuan?)
Do you know of any other reason why you should not do physical activity?
(Meron ka bang alam na iba pang dahilan kung bakit hindi ka dapat gumawa ng kahit ano
mang gawaing pisikal?)

If you answered YES to any question, please see an EIM certified specialist. Thank you.
(Pag may sinagutan kayo ng “YES”, maari lang magpakita sa EIM certified specialist. Salamat.)
 If you answered NO to all of the questions above, you are cleared for physical activity.
Please sign the PARTICIPANT DECLARATION. You do not need to complete Pages 2 and 3.

 Start becoming much more Physically Active-start slowly and build up gradually.
 Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/.)
 You may take part in a health and fitness appraisal.
 If you are over the age of 45 and NOT accustomed to regular vigorous to maximal effort exercise,
consult a qualified exercise professional before engaging in this intensity of exercise.
 If you have any further questions, contact a qualified exercise professional.

PARTICIPANT DECLARATION
If you are less than the legal age required for consent or require the assent of a care provider, your parent,
guardian or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I
acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is
completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness
center may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of
the same, complying with applicable law.

NAME ____________________________________________ DATE ______________________________

SIGNATURE ________________________________________ WITNESS ___________________________
SIGNATURE OF PARENT/GUARDIAN/CARE PROVIDER ______________________________________________

If you answered YES to one or more of the questions above, COMPLETE PAGES 2 AND 3.

Delay of becoming more active if:

 You have temporary illness such as cold or fever; it is best to wait until you feel better.
 You are pregnant-talk to your health care practitioner, your physician, a qualified exercise professional,
and/or complete the ePARmed-X+ at www.eparmedxcom before becoming more physically active.
 Your health changes-answer the questions on Pages 2 and 3 of this document and/or talk to your
doctor or a qualified exercise professional before continuing with any physical activity program.
Table 1.2 Definitions of Major Symptoms and Signs

SIGN OR SYMPTOM CLARIFICATION//SIGNIFICANCE

One of the cardinal manifestations of cardiac disease, in particular coronary artery
disease.
Key features favouring an ischemic origin include:
 Character: Constricting, squeezing, burning, “heaviness” or heavy
“feeling”
 Location: Substernal, across midthorax, anteriorly, in one or both arms,
Pain, discomfort (or other angina shoulders, in neck, cheeks, teeth, in forearms, fingers in interscapular
equivalent) in the chest, neck, jaw, region.
 Provoking factors: Exercise or exertion, excitement, other forms of stress,
arms or other areas that may result
cold weather, and occurrence after meals.
from ischemia. Key features against ischematic origin include:
 Character: Dull ache; “knifelike”, sharp, stabbing; “jabs: aggravated by
respiration
 Location: In left sub mammary area; in left hemithorax
 Provoking factors: After completion of exercise, provoked by a specific
body motion
Dyspnea (defined as an abnormally uncomfortable awareness of breathing) is one
of the principle symptoms of cardiac and pulmonary disease. It commonly occurs
Shortness of breath at rest or with during moderate exertion in healthy, untrained persons. However, it should be
mild exertion regarded s abnormal when it occurs at a level of exertion in healthy that is not
expected to evoke symptom in given individual. Abnormal exertional dyspnea
suggests the presence of cardiopulmonary disorders in particular left ventricular
dysfunction or chronic obstructive pulmonary disease.
Syncope (defined as a loss of consciousness) is most commonly caused by a
reduced perfusion of the brain. Dizziness and, in particular, syncope during
exercise may result from cardiac disorders that prevent the normal (or an actual
fall) in cardiac output. Such cardiac disorders are potentially life-threatening and
include severe coronary artery disease, hypertrophic cardiomyopathy, aortic
Dizziness or Syncope stenosis, and malignant ventricular dysrhythmias. Although dizziness or syncope
shortly after cessation of exercise should not be ignored, these symptoms may
occur even in a healthy person as a result of a reduction in venous return to the
heart.
Orthopea refers to dyspnea occurring at rest in the recumbent position that is
relieved promptly by sitting upright or standing. Paroxysmal nocturnal dsypnea
refers to dyspnea, beginning usually 2-5 hour after the onset of sleep, which may
Orthopea or Paroxysmal nocturnal be relieved by sitting on the side of the bed or getting out of bed. Both are
dyspnea symptoms of left ventricular dysfunction. Although nocturnal dyspnea may occur
in person with chronic obstructive pulmonary disease, it differs in that is usually
relieved after the person relieves himself or herself secretions rather than
specifically by sitting up.
Bilateral ankle edema that is most evident at night is a characteristic sign of heart
Ankle Edema failure or bilateral chronic venous insufficiency. Unilateral edema of a limb often
results from venous thrombosis or hymphatic blockage in the limb. Generalized
edema (known as anasarca) occurs in persons with the nephritic syndrome, severe
heart failure, or herpetic cirrhosis.
Palpitations (defined as an unpleasant awareness of the forceful or rapid beating
of the heart) may be induced by various disorders or cardiac rhythm. These
Palpitation or tachycardia include tachycardia, bradycardia of sudden onset, ectopic beats, compensatory
pauses, and accentuated stroke volume resulting from valvular regurgitation.
Palpitation also often result from anxiety states and high cardiac output (or
hyperkinetic) states, such as anemia, fever, thytroxicosis, arteriovenous fistula,
and so called idiopathic hyperkinetic heart syndrome.
Intermittent claudication refers to the pain that occurs in a muscle with an
adequate blood supply (usually as a result of atherosclerosis) that is stressed
Intermittent claudication exercised. The pain does not occur with standing or sitting, is reproducible from
day to day, is more severe when walking upstairs or up a hill, and is often
described as a cramp, which disappears 1-2 minutes after stopping exercise.
Coronary artery disease is more prevalent in person with intermittent
claudication. Patients with diabetes are at increased risk for this condition.
Although some may be innocent, heart murmurs may indicate valvular or other
Known Heart Murmur cardiovascular disease. From and exercise standpoint, it is especially important to
exclude hypertrophic cardiomyopathy and aortic stenosis as underlying causes
because there are among the more common causes of exertion-related sudden
cardiac death.
Unusual fatigue or shortness of breath Although there may be benign origins for these symptoms, they also may signal
with usual activities the onset of, or change in the status of cardiovascular, pulmonary, or metabolic
disease.