Risk Assessment Questionnaire
SSN:	Member Name:	Risk Assessment Date:

Coronary Artery Disease Risk Factors
Are you a male greater than 40 years old or a female greater than 50 years old and do not participate in a consistent aerobic exercise activity three to five times weekly?		Yes No
Has your mother or sister died without any explanation (sudden death) or suffered from a heart attack before the age of 55		Yes No
Has your father or brother died without any explanation (sudden death) or suffered from a heart attack before the age of 45?		Yes No
Are you a current tobacco user?		Yes No
Do you have high blood pressure or are you on blood pressure medication?		Yes No
Has a doctor ever told you that you have high cholesterol or are you on cholesterol medication?		Yes No
Do you have diabetes?		Yes No
Are you sedentary (don't exercise at least three to five times per week for at least 30 minutes)?		Yes No
Do you have any personal history of metabolic disease (thyroid, renal, liver)?		Yes No
Have you ever passed out during exercise?		Yes No
Have you ever been told you have a heart murmur?		Yes No
Have you ever been dizzy or lightheaded during or after exercise?		Yes No
Do you have known cardiac (heart) disease?		Yes No
Has a health care provider ever denied or restricted your participation in sports?		Yes No
Do you tire more quickly than your friends do during exercise?		Yes No
Signs & Symptoms
Do you feel pain in your chest, neck, jaw, or arms when doing physical activity?		Yes No
Do you experience any shortness of breath with moderate continuous exercise?		Yes No
In the last month, have you felt chest pain at rest?		Yes No
Have you had a severe viral infection such as myocarditis or mononucleosis within the past month?		Yes No
Have you experienced episodes of rapid beating or fluttering of the heart?		Yes No
Have you unintentionally lost or gained more than 10 percent of your body weight since the last PFA?		Yes No
Do you suffer from lower leg swelling of both legs?		Yes No
Do you have difficulty breathing or have sudden breathing problems at night?		Yes No
Do you have a bone, joint, or muscle problem that may prevent you from doing physical activity of any kind?		Yes No

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