PE 11 – Physical Activities toward Health and Fitness (PATH Fit)
Form 1 Module 1- Movement education
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Health Appraisal Record
I. Personal Data
Name : Maurice Althea T. Hilot Gender: Female Age : 19
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The Health Appraisal Record is designed to identify the medical and physical conditions of the participants.
All information entered in the form will be dealt with confidentiality. At the beginning of the course the
learner/participant will undergo battery of tests, and the results will be evaluated and will serve as basis for creating
an exercise plan. At the end of the course, the leaner/participant will be re-tested to check improvements.
That signing this form is an acknowledgement that as participant of the tests and/or exercise, they are fully
aware that they will be performing exercises and/or undergo tests, and that these tests and/or exercises can/may
cause discomfort. That, upon signing the form, they are fully aware about the risks of their participation in the tests
and/or exercises, and at the same time, they accept responsibility for their actions while performing the tests or the
exercises.
That upon signing this form, they signify that they are fully aware about the benefits and the risks of the
tests and/or the exercises, and at the same time, they can withdraw or discontinue participating in both or either the
tests or the exercises. That the information revealed in the form is revealed by the participant voluntarily, as
indicated in the Health Appraisal Record and Informed Consent.
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II. Physical Check-up Result
Height : 146 cm Weight : 46 kg Waistline : 28 inches
Resting Pulse Rate : 63 Ponderal Index : 14.78 Body Type : Rectangle
III. Medical-related Questionnaire
Please answer by checking the appropriate column, as honestly as possible:
Questionnaire Yes No
1 Have you had any hospitalization/surgery for the last 5 years? /
If yes, please indicate the nature of hospitalization/surgery
2 Have you sustained major injury for the last 5 years? /
If yes, please describe the nature of the injury
3 Have you experienced or have been diagnosed with, any or all of the following:
3.1 Chest pain /
3.2 Difficulty breathing /
3.3 Dizziness or fainting spell /
3.4 Hypertension (High Blood Pressure) /
3.5 Anemia /
3.6 Kidney problem /
3.7 Arthritis /
3.8 Gout /
3.9 Dislocation /
3.10 Fracture /
4 Have you experienced lower back pain? /
5 Do you have ailments which restrict movement or physical activity? /
6 Are you under medical treatment? /
7 Do you engage in regular exercise (at least 3 times a week) /
If yes, how long do you exercise (30 minutes, 1 hour, etc.)? 20 minutes
8 Do you smoke? /
If yes, how many sticks a day?
9 Do you drink alcoholic beverages? /
If yes, how often?
I certify as to the correctness of the answers to the above questions.
___MAURICE ALTHEA T. HILOT___ ____MARIE CHERYL T. HILOT __
Signature of student above printed name Signature of parent/guardian above printed Name
