Form FS-5100-31 Health Screening Questionnaire

                                                                                                           FS-5100-31 (v. 3/2016)

                                                                                               OMB No. 0596-00164

HEALTH SCREENING QUESTIONNAIRE

Name:_______________________________________ Date:____________________________

Level of test: _____ Light _____ Moderate _____ Arduous

Assess your health needs by marking all true statements.

The purpose of the HSQ is to identify individuals who may be at risk while taking the Work Capacity Test (WCT) and recommend an exercise program and/or medical examination prior to taking the WCT.

Employees are required to answer the following questions which were designed to identify those individuals who may be at medical risk when taking the WCT. This is not a medical exam. Any medical concerns you have that may put you or your health at risk should be reviewed with your personal physician prior to participating in the WCT.

SECTION A___________________________________________________________________

You have/had: You experience:

____ a heart attack ____ chest discomfort/pain with exertion

____ heart surgery ____ breathlessness more than others with

____ coronary (heart) angioplasty or exertion

stent placement ____ dizziness, fainting, blackouts

____ a pacemaker/implantable cardiac ____ muscle or bone/joint problems: spine,

defibrillator/rhythm disturbance knees, back, hips, shoulders, etc.

(abnormal heartbeat) (swelling, moderate pain)

____ heart valve disease or a heart murmur

____ heart failure Other Health Issues:

____ heart transplantation ____ you have a hernia

____ congenital (born with) heart disease ____ you take heart or asthma medications

____ personal experience or a doctor’s ____ you have epilepsy or a seizure disorder

advice of any other physical reason ____ you have a history of past heat that

that would prohibit you from carrying would exhaustion/stroke that required

out or participating in strenuous medical care

activity ____ I have a waiver for _______________

SECTION B___________________________________________________________________

Cardiovascular risks: ____ your blood cholesterol level is greater

____ you are physically inactive (i.e. you get less than 200 mg/dL, or your HDL is less

than 30 minutes of physical activity less than than 40 mg/dL, or you take cholesterol

3 days per week) medication

____ you smoke currently or in the past 6 months ____ you don’t know your cholesterol level

____ your blood pressure is greater than 139/89, ____ you are diabetic: diet controlled or you

or you take blood pressure medication take medicine to control your blood

____ you don’t know your blood pressure sugar

____ you have a body mass index (BMI) ≥ 30*

*To determine go to: http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

I understand that if I need to be evaluated by a physician, it will be based on the fitness requirements of the position(s) for which I am qualified.

I have read and understand the above and answered truthfully.

Signature________________________________________ Date _________________________

Printed Name __________________________________________________________________

Unit:______________________________________ HSQ Coordinator:____________________