6.4 Preparticipation Health Screening & Level of Monitoring (PAR-Q+, ACSM algorithm, ACC/AHA · GOLD · ADA · AACVPR)

Preparticipation Health Screening & Level of Monitoring (PAR-Q+, ACSM Algorithm, ACC/AHA · GOLD · ADA · AACVPR)

Quick Answer: Preparticipation screening answers one operational question: does this patient need medical clearance before starting or progressing an exercise program, and at what level of monitoring should sessions occur? ACSM's current algorithm answers that using three factors — current activity status, presence of signs/symptoms or known cardiovascular, metabolic, or renal disease, and desired exercise intensity — deliberately without counting cardiovascular risk factors, which is a separate tool covered in Section 6.2.

PAR-Q+: The Self-Guided Screening Tool

The Physical Activity Readiness Questionnaire for Everyone (PAR-Q+) is a brief, self-administered screening tool commonly used in general fitness and community settings. A "yes" answer to any of its core general-health questions triggers condition-specific follow-up pages or a recommendation to consult a qualified exercise professional or physician before proceeding. In the clinical CEP setting, PAR-Q+ typically serves as a first-pass filter; the more clinically detailed ACSM algorithm below is what actually governs the medical-clearance decision for patients already in, or being referred into, clinical exercise programs.

ACSM's Current Preparticipation Screening Algorithm

The algorithm evaluates three factors:

1. Current exercise participation — is the patient "regularly active," defined as performing at least 30 minutes of moderate-intensity physical activity on at least 3 days per week for at least 3 months?
2. Signs/symptoms and/or known disease — does the patient have any signs or symptoms suggestive of cardiovascular, metabolic, or renal disease, or a known diagnosis of such disease?
3. Desired exercise intensity — is the patient planning light-to-moderate intensity, or vigorous intensity, activity?

A deliberate design choice distinguishes this algorithm from older screening tools: it does not ask about CVD risk-factor counts such as age or family history. ACSM removed risk-factor-based screening from the general clearance decision because it was shown to be overly conservative, referring large numbers of low-risk adults for unnecessary medical clearance and creating a barrier to exercise participation.

The Decision Logic

Active signs or symptoms always override activity history — a regular exerciser who develops new symptoms is handled the same as anyone else with symptoms: stop and refer for clearance.

Disease-Specific Frameworks That Feed the Clearance Decision

For patients with an established diagnosis, the general algorithm above is supplemented by condition-specific guidance the CEP is expected to know exists and apply appropriately:

• ACC/AHA cardiac guidelines inform risk assessment and exercise candidacy for patients with known coronary, valvular, or heart-failure disease (pathophysiology detailed in Chapter 3).
• GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging — based on spirometry (FEV₁ % predicted) and symptom/exacerbation history — informs exercise safety and intensity decisions for patients with COPD.
• ADA (American Diabetes Association) glycemic guidance shapes exercise timing and intensity decisions for patients with diabetes: exercising with a pre-session glucose above roughly 250 mg/dL accompanied by ketones is avoided, a glucose above roughly 300 mg/dL even without ketones calls for caution with lighter intensity and rechecks, and a glucose below 70 mg/dL must be treated before exercise begins.
• AACVPR (American Association of Cardiovascular and Pulmonary Rehabilitation) risk-stratification criteria (low/moderate/high risk) set formal program-entry criteria and supervision requirements specifically for cardiac and pulmonary rehabilitation programs.

Exam Tip: Don't Mix Up the Two Tools

A frequent point of confusion — and a favorite exam trap — is treating the ACSM CVD risk-factor count from Section 6.2 as the input to this algorithm. It is not. The current preparticipation algorithm uses only the three factors above (activity status, disease/symptoms, desired intensity). The eight-positive/one-negative risk-factor count is used elsewhere, specifically for stratifying supervision needs during maximal exercise testing (Chapter 7). A patient with five positive risk factors but no symptoms who already exercises regularly may still not need medical clearance under this algorithm — read each tool's actual inputs rather than assuming risk factors always drive the clearance decision.

From Clearance to Level of Monitoring

Once clearance status is resolved, the same intake information — disease history, risk stratification, and current signs/symptoms — determines the level of monitoring during sessions, ranging from unsupervised self-monitoring, to intermittent professional supervision, to continuous ECG telemetry, pulse oximetry, or glucometry during every session. This decision is revisited continuously, not just at intake; Chapter 9 covers how monitoring intensity is adjusted as a patient's clinical status changes over the course of a program.