Fitness Law Academy

Enhancing Fitness Safety through Education

Pre-Activity Screening Questionnaires and Related Forms

ACSM made significant changes in their pre-activity screening criteria -- please see ACSM Guidelines for Exercise Testing and Prescription (10th edition). We published an article in ACSM’s Health & Fitness Journal entitled “Putting the New ACSM Pre-Activity Screening Guidelines into Practice” in the May/June 2017 issue. You can access this article for free at:

Putting the New ACSM's Pre-Activity Health Screening Guidelines into Practice


In this article, we included the following forms and a description on how to implement them as well as legal issues that are applicable to pre-activity screening. Please read this article before using any of these forms and note the following regarding the files below:


For professionally-guided screening:

The first 2 files below (PASQ Figures 1 and 2) below are PDFs. If you want to make any changes with Figures 1 and 2 – see file #3 below (this is a Word Doc). Figures 3 and 4 (file #4 below) – also Word Docs so you can easily make any changes.


For self-guided screening:

See file #5 below – this is also a Word Doc.


Regarding the Copyright Statement at the bottom of the figures/forms:

Feel free to remove this statement when using these forms in your facility. However, if you choose to publish any of these (e.g., in a book, book chapter, journal article, magazine/newspaper, Internet website, thesis/dissertation, etc.), formal permission from Dr. Eickhoff-Shemek (drjes2014@gmail.com) and the copyright statement will be necessary.


5 documents/forms:

File #1 -- PASQ – Figure 1 (PASQ) – Fillable PDF

File #2 -- PASQ – Figure 2 (Interpretation) -- Fillable PDF

File #3 -- PASQ -- Figure 1 (PASQ) and Figure 2 (Interpretation) – Word Doc

File #4 -- PASQ – Figure 3 (Cover Letter) and Figure 4 (Med. Clearance) – Word Doc

File #5 -- PASQ – Self-Guided – Word Doc