Form 0920-0109 Pre- and Post-Test Session Participant Questionnaire and

Pre- and Post-Test Session Participant Questionnaire and Examination
***To be completed by the Test Participant ***
Please complete the form below. If you do not understand a question or word, please ask.
Name: ____________________________________________

Date: __________________

Emergency Point of Contact: ________________________ Phone Number: ________________
1

Do you feel sick today?

Yes

No

2

Have you had a cold, flu, or illness within the last two weeks? (if no, skip to question 4)

Yes

No

3

How long has it been since you recovered from the cold, flu, or illness (number of days)?
_______
Have you used tobacco products within the last 12 hours?

Yes

No

Yes

No

Have you consumed caffeine or supplements within the past 24-30 hours? (if yes, How
much caffeine or which supplements?
______________________________________________
6 Have you been fasting for more than 4 hours? (if yes, when did you last eat?)
____________________________________________________________
7 Do you feel dehydrated? (if yes, when did you last drink fluids?)
____________________________________________________________
8 Have you started or stopped taking any medications (or changed doses) since your last
physical exam? If yes, please explain
________________________________________________________________________
9 Take a few minutes to review the activity sheet(s) for the test you will be performing
today. Do you have any concerns about being able to complete these tasks safely?
If yes, please explain
____________________________________________________________
10 Have you had any illness or injury that required you to see or seek healthcare since your
last physical exam?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

11 Are you pregnant or could you possibly be pregnant?

Yes

No

12 Have you experienced any of the following conditions since your last physical exam with
your physician? (if yes, please circle)
• Shortness of breath
• Fainting or dizzy spells
• Wheezing
• Any other lung or heart problems
• Pain or tightness in your chest
• Unusual, severe headaches
• Irregular heartbeat
• Numbness or tingling in extremities
• High or low blood pressure
• Pain or discomfort in your legs
associated with walking
• Have you had a seizure

Yes

No

4
5

Participant Signature

Date

Page 1 of 4

ETB-1035 Rev 1

Pre- and Post-Test Session Participant Questionnaire and Examination
***To be completed by the Medical Monitor ***
Date__________________________

Participant Name__________________________________________

Tests to be done:  Fit Testing
 Cold Temperature♥
♥
♥
 Man Test 2 *  Man Test 3 *  Man Test 4♥*
 Breathing Gas Determination♥
 LTFE Treadmill♥
 Other:___________

 Noise Level
 Man Test 1♥
 Man Test 5
 Man Test 6
 Multiple-Workrate Treadmill♥*
___________________________

Pre-Test Examination

Vital Signs

Session Start Time:

Temperature
O2 saturation on RA
Respirations/minute
Heart rate/minute
Blood pressure

System

Right/Left

WNL

ABN

System
Cardiovascular

Alert, oriented, calm, no acute
distress, Other:

No heaves/thrills

PERRLA

No Murmurs

EOMI, NCAT

Other:

Respiratory
CTAB, Nl excursion, No
W/R/R
Other:

Abdomen
Soft, flat, non-tender, and nondistended, BS pos.
Other:

ABN

Regular rate and rhythm

HEENT

Pink and moist mucous
membranes in oropharynx
Other:

WNL

Musculoskeletal
Gait Nl
ROM Nl

Other:

Neurological
Reflexes and strength Nl
Other:

WNL: Within Normal Limits, ABN: Abnormal, NA: Not Assessed

Abnormal findings or additional comments: _____________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Page 2 of 4

ETB-1035 Rev 1

Pre- and Post-Test Session Participant Questionnaire and Examination
I certify that I have examined the subject and completed the Pre-Test Evaluation:
No exclusions identified

Excluded from participation

Post-Test Examination

Vital Signs

Session End Time:

Temperature
O2 saturation on RA
Respirations/minute
Heart rate/minute
Blood pressure

System

Right/Left

WNL

ABN

System
Cardiovascular

Alert, oriented, calm, no acute
distress, Other:

No Carotid Bruits

PERRLA

No Murmurs

EOMI, NCAT

Other:

Respiratory
CTAB, Nl excursion, No
W/R/R
Other:

Abdomen
Soft, flat, non-tender, and nondistended
Other:

ABN

Regular rate and rhythm

HEENT

Pink and moist mucous
membranes in oropharynx
Other:

WNL

Musculoskeletal
Gait Nl
ROM Nl

Other:

Neurological
Reflexes and strength Nl

WNL: Within Normal Limits, ABN: Abnormal, NA: Not Assessed

Abnormal findings or additional comments: _____________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Page 3 of 4

ETB-1035 Rev 1

Pre- and Post-Test Session Participant Questionnaire and Examination

Medical Monitor Printed Name: ____________________________________________
Signature ___________________________ Date:

/

/

Time:____________ AM/PM

Participant denies any issues or complaints. They state that they feel “well” and are discharged from
testing today.
Other________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature ___________________________ Date:

/

/

Page 4 of 4

Time:____________ AM/PM

ETB-1035 Rev 1