Begin FSQ

1. Have you experienced any of the symptoms/problems listed below and not been medically evaluated and cleared for unrestricted participation in a physical training program?

a. Unexplained chest discomfort with or without exertion

b. Unusual or unexplained shortness of breath

c. Dizziness, fainting, or blackouts associated with exertion

d. Other medical problems that have not been evaluated, optimally treated, or not already addressed in an AF Form 469, that may prevent you from safely participating in this test (e.g. heart disease, sickle cell trait, asthma, etc)

e. Are you taking any medication that may affect the heart rate or the heart’s response to exercise?

Start Over No Yes

2. Can you verify that you know your sickle cell trait (SCT) screening test result and that if you have SCT, you completed at least 2 counseling sessions with a health care provider and watched the educational video within the past year (https://www.hprc-online.org/articles/sickle-cell-trait-awareness OR https://www.youtube.com/watch?v=8s9nKcFd-Fk) SCT screening results can be located at https://imr.afms.mil/imr/myIMR.aspx

Start Over No Yes

3. Are you 35 years of age or older?

Start Over No Yes

4. Have you engaged in vigorous physical activity (i.e., activity causing sweating and moderate to marked increase in breathing and heart rate) averaging at least 30 minutes per session, 3 days per week, over the last 2 months?

Start Over No Yes

5. Do one (1) or more of the following risk factors apply to you?

a. Smoked tobacco products in the last 30 days

b. Diabetes

c. High blood pressure that is not controlled

d. High cholesterol that is not controlled

e. Family history of heart disease (developed in father/brother before age 55 or mother/sister before age 65)

f. Age > 45 years for males; > 55 years for females

Start Over No Yes

Start Over Clear Signature Generate FSQ

Stop. If you have answered Yes to any of the Above Questions, circle the symptom and notify your UFPM and contact your PCP/MLO for evaluation/recommendations (or for ARC, contact the MLO for Duty Limiting Conditions (DLC) documentation and referral to PCP). Hand carry this form to medical evaluation.

Start Over

Stop and notify your UFPM and your Primary Care Provider.

Start Over

Stop. If you have answered Yes to any of the Above Questions circle the Risk Factor and notify your UFPM

Start Over