Sample Participant Health Screening Form

SAMPLE PARTICIPANT HEALTH SCREENING FORM

[Statements in bold indicate decision making criteria and will not be included in form distributed to participants. Questions can be added or removed from this form to address study risks.]

Name (please print): ______

Date of Birth: Day ______Month ______Year ______

Height ______Weight ______Sex M / F (please circle one)

Briefly describe your typical weekly physical exercise. Indicate the approximate duration, frequency, and intensity. For example: " I cycle 20 miles, 3 times per week at 15mph." or "I walk to school every day, about a mile", or "no regular exercise".

______

To the best of your knowledge:

Are you in good general health? Yes No

A “no” answer will result in exclusion from the study

If you are female, are you pregnant? Yes No

A “yes” answer will result in exclusion from the study

Do you have any difficulty with walking, running or mobility in general? Yes No

A “yes” answer will result in exclusion from the study

Do you have any problems with balance or dizziness? Yes No

A “yes” answer will result in exclusion from the study

Have you ever experienced a serious musculoskeletal injury in your legs, feet or back? (e.g. fractures, ligament injuries, etc.)

Yes No

If yes, please briefly describe the nature of the injury and approximate date. ______
______

Exclusion: any injury that has required surgical repair, any injury with lingering problems (see next question)

Do you currently have lingering symptoms or pain related to that injury (injuries)? Yes No

A “yes” answer will result in exclusion from the study

Have you ever experienced chest pain or shortness of breath with exertion? Yes No

A “yes” answer will result in exclusion from the study

Do you have hypertension (high blood pressure)? Yes No

A “yes” answer will result in exclusion from the study

Have you ever had a heart attack? Yes No

A “yes” answer will result in exclusion from the study