PRE-PARTICIPATION EVALUATION

NAIROBI FITNESS CONSULTING

PRE-PARTICIPATION EVALUATION

Designed to determine whether individuals need medical clearance before starting or increasing the intensity of a physical activity program.

NBOFITNESS.com

Pre-Participation Evaluation

Personal Information

Name:

Age:

Gender:

Date:

1. Do you currently engage in regular physical activity (≥30 min, 3x/week)?

Yes
No

2. Have you ever been diagnosed with any of the following?

Heart disease
Stroke or TIA
Diabetes (Type 1 or 2)
Chronic kidney disease
COPD, asthma, or lung conditions
Other cardiovascular/metabolic/renal
None of the above

3. Do you currently experience any of the following symptoms?

Chest discomfort with exertion
Breathlessness at rest or mild exertion
Dizziness or fainting
Ankle swelling
Heart palpitations
Leg pain while walking
Known heart murmur
Unusual fatigue
None of the above

4. What intensity of exercise do you plan to begin?

Light
Moderate
Vigorous

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PRE-PARTICIPATION EVALUATION SYSTEM

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“Our services provide a luxury experience designed for convenience and efficacy. We tailor each program to fit the unique needs of high-performing individuals, to stay on track to optimal health, if you demand both excellence and convenience.”