Preparticipation
screening questionnaire

To quickly assess your need for medical evaluation, use the preparticipation screening questionnaire below. It is of utmost importance to be honest with yourself when it comes to the conditions and symptoms in the questionnaire. Remember, you hold the key to your safe participation in physical exercise or scuba diving.

Section 1: History

Do you have a history of any of the following?

heart attack
heart surgery
cardiac catherization
coronary angioplasty (PCI)
pacemaker/implantable cardiac defibrillator/rhythm disturbance
heart valve disease
heart failure
heart transplantation
congenital heart disease

Do you experience any of the following?

chest discomfort with exertion
unreasonable breathlessness
dizziness, fainting, blackouts

Mark any of the following statements that apply:

You have musculoskeletal problems.
You have concerns about the safety of exercise.
You take heart medications.
You take prescription medication(s).
You are pregnant.

If any of the statements in Section 1 apply to you, consult your health care provider before engaging in exercise. You may need to use an exercise facility staffed with medically qualified personnel.

Section 2: Cardiovascular risk factors

Mark any of the following statements that apply:

You are a man older than 45.
You are a woman older than 55 or you have had a hysterectomy or are postmenopausal.
You smoke.
Your blood pressure is greater than 140/90 or you do not know your blood pressure.
You take blood pressure medication.
Your cholesterol level is greater than 240mg/dl or you do not know your cholesterol level.
You have a close relative who had a heart attack before age 55 (father or brother) or 65 (mother or sister).
You have diabetes or take medicine to control your blood sugar.
You are physically inactive (i.e., you get less than 0 minutes of physical activity at least three days each week).
You are more than 20 pounds overweight.

If any two or more of the statements in Section 2 apply, consult your health care provider before engaging in exercise. You might benefit from using a facility with a professionally qualified staff to guide your exercise program.

If none of the above statements in Section 1 and 2 are applicable, you should be able to exercise safely in almost any facility that meets your exercise program needs without consulting your health care provider.

Adopted from Balady GJ, et al. Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities. Circulation 1998; 97:2283-2293. doi.org/10.1161/01.CIR.97.22.2283

Travelers Medical Guide

DAN Customer Service

Mon–Fri, 8:30 a.m. – 5 p.m. ET

+1 (919) 684-2948

+1 (800) 446-2671

Fax: +1 (919) 490-6630

Email:

24/7 Emergency Hotline

In event of a dive accident or injury, call local EMS first, then call DAN.

24/7 Emergency Hotline:

+1 (919) 684-9111

(Collect calls accepted)