# description
Pre-visit intake for the Benchmark Assessment: medical history, exercise-readiness screening, informed consent, and goals. Completed by the member before assessment day.

# purpose
FIRST-PASS STRUCTURE — requires clinical review and sign-off before use with members. The exercise-readiness items are generic screening questions written for this form; they are NOT the PAR-Q+, which is a copyrighted CSEP instrument. If the PAR-Q+ specifically is wanted, license it and replace the exercise-readiness group verbatim.

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Please list any medical conditions you have been diagnosed with.

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Please list any surgeries or hospitalizations, with approximate dates.

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List all medications, supplements, and peptides you currently take, including dose.

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List any drug, food, or environmental allergies and the reaction.

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Has a first-degree relative had heart disease, stroke, diabetes, or cancer before age 60?

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Describe your current tobacco, nicotine, and alcohol use.

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Has a clinician ever told you that you have a heart condition, or that you should only do physical activity supervised by a clinician?

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Do you experience chest pain, pressure, or discomfort during physical activity?

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In the past month, have you had chest pain, pressure, or discomfort at rest?

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Do you lose balance from dizziness, or have you lost consciousness, in the past 12 months?

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Do you have a bone, joint, or soft-tissue problem that could be made worse by physical activity?

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Are you currently taking medication for blood pressure or a heart condition?

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Is there any other reason you should not perform maximal exercise testing?

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If you answered yes to any of the above, please give details.

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I consent to the Benchmark Assessment, including blood draw, DXA scan with low-dose ionizing radiation, force-plate testing, and maximal cardiopulmonary exercise testing.

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I understand that results are released only after physician review, and that lab results are not released at the same-day debrief.

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I understand I must fast for 10-12 hours before the assessment, water permitted.

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What is the single most important thing you want from this assessment?

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Over what horizon are you thinking about your health?

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Describe your current training: modality, frequency, and years of consistency.