Proper screening and risk stratification of clients who are starting exercise programs is important for promoting exercise safety and preventing adverse events during exercise. Personal fitness trainers (PFTs) must be able to utilize the proper tools and understand the information gathered from the exercise screening. Components of this screening include the health history questionnaire (HHQ); physical activity readiness questionnaire (PAR-Q); risk stratification; and informed consent.
HHQ and PAR-Q
The HHQ and PAR-Q are critical first steps in the exercise screening process. They help exercise professionals to determine whether clients need physician referral before starting an exercise program; to recognize clients who require exercise program modifications based on physical limitations; and to identify clients for whom exercise training would be inappropriate or unsafe.
Administering HHQs to clients should be standard procedure for all PFTs. However, the information collected using an HHQ may vary by facility. In general, HHQs should cover a number of basic areas:
- demographic information (including
health care provider information)
- medical diagnoses (cardiovascular,
pulmonary, metabolic, musculoskeletal
- history of symptoms for disease (chest
pain, dizziness, shortness of breath,
palpitations, musculoskeletal pain, etc.)
- family history (primarily immediate
family, including mother, father,
- previous physical exam, lab and exercise
- recent illnesses, hospitalizations,
medications and allergies
- health habits (diet, stress, tobacco,
alcohol, etc.) and exercise/work history
- pregnancy status
The PAR-Q is considered a minimal standard screening tool for clients starting a moderate-intensity exercise program and should be used in conjunction with the HHQ. The PAR-Q is mostly used to identify when physical activity would be inappropriate for a client or whether a client should seek medical advice before starting a program. The PAR-Q consists of seven questions referring to signs or symptoms suggestive of diseases that exercise can exacerbate. The questions have simple yes or no answers. If clients answer yes to any of the questions, they should be referred to a physician for further screening. A copy of the PAR-Q can be found in ACSM’s Guidelines for Exercise Testing and Prescription (6th edition) if one is not readily available to you.
Risk Factors and Risk Stratification
Some of the most important items that should be identified with these screening tools are coronary artery disease (CAD) risk factors (see Table 1 on page 39). These risk factors can be associated with the overall promotion or development of CAD (seven positive risk factors!) or with the prevention of CAD (one negative risk factor!). Interestingly, risk factors can be summed to obtain a total number of factors, with a negative risk factor canceling out a positive risk factor if both are present. ACSM suggests that the list of risk factors not be considered all-inclusive, but rather be used as a guideline when determining if physician referral and further evaluation are needed before beginning a program.
Once the HHQ and PAR-Q are complete, individual clients can be evaluated based on their risk of experiencing an adverse cardiovascular event during exercise. According to the American College of Sports Medicine (ACSM), PFTs can stratify a client’s risk using variables such as age, risk factors, and symptoms suggestive of disease. The “Initial ACSM Risk Stratification” screening defines three risk categories:
1. Low Risk: younger individuals who are asymptomatic and meet no more than one risk factor threshold (from the CAD risk factor chart).
2. Moderate Risk: older individuals (men > 45 years of age; women > 55 years of age) or those who meet the threshold for two or more risk factors (from the CAD risk factor chart).
3. High Risk: individuals with known cardiovascular or pulmonary disease; known metabolic disease, such as type 1 or type 2 diabetes; or one or more signs/symptoms suggestive of any of these diseases.
Once clients are stratified according to risk, trainers should use a standard such as the “ACSM Recommendations” in Table 2 on page 40 to determine whether their clients should be referred to a physician for a thorough medical exam prior to beginning either a moderate or vigorous exercise program.
The last step in the exercise screening process should provide an opportunity for all clients to give informed consent before beginning an exercise program. The informed consent document can vary among facilities depending on clientele, staff, equipment, etc., but all informed consents should be written in an understandable manner and include certain basic information:
- purpose of the consent
- degree of exercise supervision (i.e.,
close monitoring, occasional monitoring)
- benefits and risks of exercise
- steps or procedures that will be
followed in an emergency situation
- responsibilities of the client (i.e.,
reporting of symptoms, exercise
- statement covering confidentiality and
freedom of consent to participate in
True informed consent can be obtained only when the personal trainer verbally communicates the meaning of the form to the client (simply asking the client to read and sign it does not constitute informed consent). Provide an opportunity to answer client questions before the client and witness add their signatures. Since most legal claims against exercise professionals occur based on negligence or malpractice, having a signed informed consent on file can help prove that the client intentionally engaged in the exercise program after full disclosure and examination of risks associated with exercise participation.
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