Pre-Activity Screening Form

*First name:

*Last name

*Cell or Home Phone

*Work Phone

*Email address:

*Gender

*Date of Birth

*Has your physician or provider ever told you that you have a heart condition?

*Do you experience pain in your chest when you are physically active

*Do you lose balance because of dizziness or do you ever lost consciousness?

*Do you have a bone or joint problem that could be aggravated by a change in your level of physical activity?

*Is your physician or provider currently prescribing medications for your blood pressure or a heart condition?

*Do you currently participate in any rehabilitative medicine programs (physical, occupational, cardiac or other rehabilitation)?

If you answered “yes” to any of these questions, you may be eligible to qualify for our medical fitness program. You will be contacted by a representative of Labette Health’s The CORE and be invited to participate in a complete Wellness Profile to determine specific need areas.

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