LESSON 1 Activity 1: The Health Appraisal Record is designed to determine

individual’s safety in starting an exercise plan. It is important to fill up the form before
engaging in any physical activity.

HEALTH APPRAISAL RECORD

I. PERSONAL DATA:
Name: john albert S. alejandrino Gender: Male Age: 28

II. PHYSICAL AND MEDICAL EXAMINATION

Height: _5,4___ Resting Pulse Rate: 74 / min___

Weight: _51kg__ Blood Type: _0_______
Date of Last Medication: _______________

III. QUESTIONNAIRE:
To be further of assistance to you, please answer and/or check answer of the
following questions.

Yes, _____ No ____

please indicate nature of
Any hospitalization/ surgery since last medical injury/ injuries?
examination?

1. Any injury sustained last medical YES, NO

examination?
What was the nature of
injury/ injuries?
2. Have you had any of the
following;

a. Chest Pain or difficulty of breathing on Yes, _______No _______

physical exertion?

b. Frequent dizziness or fainting spells? Yes, _______No _______

c. Asthma? Yes, _/__No _______

d. Other lung diseases? Yes, _______No _______

e. Diabetes? Yes, _______No _______
f. High Blood Pressure? Yes, _______No _______
g. Anemia? Yes, _______No _______
h. Kidney Trouble/ Disease? Yes, _______No _______
i. Arthritis? Yes, _______No _______
j. Gout? Yes, _______No _______
 k. Dislocation? Yes, ____/__No _______
l. fractures? Yes, __/____No _______
3. At present, do you have lumbar/lower back Yes, _______No /___
pain?
4. Other ailments which you have at present that Please specify _________
may in a way restrict your physical activity
5. Are you now under treatment? Yes, _______No ___/___
6. Do you engage in regular exercise? Yes, _/_____No _______

7. How often do you exercise? 6 times a week 1 rest day

8. How long do you exercise? 30 min weight training

30min conditioning

9. When was the last time you exercise? today

10. Do you smoke? Ye before but I stop for

almost 1 year already

11. Do you drink alcohol beverages? Stop for almost 2 months

already
I certify as to the correctness of the answers to the above questions

John albert S. Alejandrino 3/12/2021

Name and Signature of Students Date

Jinky S. Alejandrino 3/12/2021

Name and Signature of Parent Date