PE 11 – Physical Activities toward Health and Fitness (PATH Fit)

Module 2 – Safety protocols & Exercise

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Health Appraisal Record

I. Personal Data
Name : Gender Age :
:
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The Health Appraisal Record is designed to identify the medical and physical conditions of the participants. All
information entered in the form will be dealt with confidentiality. At the beginning of the course the learner/participant will
undergo battery of tests, and the results will be evaluated and will serve as basis for creating an exercise plan. At the
end of the course, the leaner/participant will be re-tested to check improvements.
That signing this form is an acknowledgement that as participant of the tests and/or exercise, they are fully aware
that they will be performing exercises and/or undergo tests, and that these tests and/or exercises can/may cause
discomfort. That, upon signing the form, they are fully aware about the risks of their participation in the tests and/or
exercises, and at the same time, they accept responsibility for their actions while performing the tests or the exercises.
That upon signing this form, they signify that they are fully aware about the benefits and the risks of the tests
and/or the exercises, and at the same time, they can withdraw or discontinue participating in both or either the tests or
the exercises. That the information revealed in the form is revealed by the participant voluntarily, as indicated in the
Health Appraisal Record and Informed Consent.
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II. Physical Check-up Result

Height : Weight : Waistline :
Resting Pulse Rate : Ponderal Index : Body Type :

III. Medical-related Questionnaire

Please answer by checking the appropriate column, as honestly as possible:
Questionnaire Yes No
1 Have you had any hospitalization/surgery for the last 5 years?
If yes, please indicate the nature of hospitalization/surgery
2 Have you sustained major injury for the last 5 years?
If yes, please describe the nature of the injury
3 Have you experienced or have been diagnosed with, any or all of the following:
3.1 Chest pain
3.2 Difficulty breathing
3.3 Dizziness or fainting spell
3.4 Hypertension (High Blood Pressure)
3.5 Anemia
3.6 Kidney problem
3.7 Arthritis
3.8 Gout
3.9 Dislocation
3.10 Fracture
4 Have you experienced lower back pain?
5 Do you have ailments which restrict movement or physical activity?
6 Are you under medical treatment?
7 Do you engage in regular exercise (at least 3 times a week)
If yes, how long do you exercise (30 minutes, 1 hour, etc.)?
8 Do you smoke?
If yes, how many sticks a day?
9 Do you drink alcoholic beverages?
If yes, how often?

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

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Signature of student above printed name Signature of parent/guardian above printed Name