Name
First Name
Last Name
Social Security Number
*
Date of Birth
*
MM
DD
YYYY
Have you had any illness or injury in the last 5 years?
*
Are you experiencing any current issues with the injured body part or as a result of illness described above?
*
Have you had surgery in the past 2 years?
*
Are you on permanent medical restrictions?
*
Current condition or medical restriction that may prevent you from safely participating in a PreWork Screen? (i.e., hernia, arthroscopy, total knee/hip, pregnancy, lymphedema, etc.)
*
Date of your last Physical Exam:
MM
DD
YYYY
Head/Brain injuries, disorders or illnesses
*
Yes
No
Seizures, epilepsy
*
Yes
No
Eye disorders or impaired vision (except corrective lenses)
*
Yes
No
Ear disorders, loss of hearing or balance
*
Yes
No
Loss of or altered consciousness
*
Yes
No
Fainting spells, dizziness or vertigo, loss of consciousness
*
Yes
No
Stroke or paralysis
*
Yes
No
Please list all medications below:
*
Heart palpitations, irregular heartbeat, chest pain
*
Yes
No
Heart disease, heart attack, other cardiovascular condition, DVT
*
Yes
No
Heart surgery (valve replacement/bypass, angioplasty, pacemaker)
*
Yes
No
Shortness of breath, lung problems
*
Yes
No
High blood pressure
*
Yes
No
Please list all medications below:
*
Muscular disease
*
Yes
No
Missing or impaired hand, arm, foot, leg, finger, toe
*
Yes
No
Spinal injury or disease
*
Yes
No
Chronic low back pain, back surgery, disc disease, back injury or sprain
*
Yes
No
Leg ulcers, swelling of ankles, leg pain or walking
*
Yes
No
Shoulder problems
*
Yes
No
Repetitive strain of arms/legs
*
Yes
No
Please list all medications below:
*
Thyroid or Metabolic
*
Yes
No
Diabetes
*
Yes
No
Rheumatic Disease
*
Yes
No
Infection (current or chronic)
*
Yes
No
Please list any medications not previously listed and the health condition for which you are taking the medication below::
*
I understand that the questions above will assist the therapist in determining my ability to safely proceed with PreWork Screen testing. My signature indicates that I have answered all questions truthfully and to the best of my knowledge.
*
First Name
Last Name
