Pre-participation screening: how to screen new clients

The short answer

Pre-participation screening helps personal trainers decide whether a new client needs medical clearance and how hard they can safely start. The American College of Sports Medicine (ACSM) bases this on four things: regular exercise, known cardiovascular, metabolic or kidney disease, signs or symptoms of those diseases, and the intensity the client wants to train at.^{1Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 131.}

Before the first session, also collect a health history questionnaire, the client’s goals and training history, and signed consent.

Why is pre-participation screening needed?

Exercise-related cardiac events are rare, but the risk is highest in people with underlying heart disease who do vigorous activity they aren’t used to. For healthy people with no symptoms, the absolute risk is low.^{1Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 131.} Pre-exercise screening helps identify clients in that higher-risk group.

NSCA’s personal training textbook describes screening as the present standard of care, to be done without exception, and notes that both the NSCA and ACSM require it before an exercise program starts.^{2Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 675.} Skipping it is hard to defend if something goes wrong. Liability rules vary by location, so treat this as background, not legal advice.

The NSCA calls trainers “suspecticians,” not diagnosticians. A blood pressure reading or an answer on a form lets you suspect that something needs a doctor’s attention. It doesn’t let you name the condition.^{2Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 675.} Trying to diagnose or treat a medical condition can count as practicing medicine without a license.^{3Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 677.}

What are the four ACSM screening questions?

ACSM’s screening algorithm works through four questions in order.

1. Does the client exercise regularly? This means planned, structured exercise at moderate intensity or harder, at least 30 minutes on 3 or more days a week, for the past 3 months.^{4Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 140.} It’s asked first because unaccustomed exertion is what puts disproportionate strain on the heart.
2. Do they have known cardiovascular, metabolic or renal disease? Ask whether a doctor or other qualified provider has ever diagnosed heart, peripheral vascular or cerebrovascular disease, diabetes, or kidney disease. For screening purposes, high blood pressure counts as a risk factor, not heart disease.^{4Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 140.} Lung disease doesn’t trigger referral on its own either, though clients with COPD deserve a careful look for heart symptoms.^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.}
3. Do they have signs or symptoms that suggest those diseases? These include chest, neck, jaw or arm pain or discomfort, shortness of breath at rest or with mild exertion, dizziness or fainting, ankle swelling, palpitations, calf cramping when walking, a known heart murmur, and unusual fatigue or breathlessness with usual activities.^{6Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 164.} Read answers in context and ask follow-up questions. Breathlessness is common and has many causes, so ask what the client was doing and whether it was more than they’d expect.^{4Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 140.}
4. How hard do they want to train? Vigorous exercise is more likely than light or moderate work to trigger a cardiac event.^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.} Moderate means 40–59% of heart rate reserve, 3–5.9 METs or an RPE of 12–13. Vigorous means 60% or more, 6 METs or more, or an RPE of 14 or higher.^{6Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 164.}

The answers sort clients into six groups based on exercise habits, known disease and symptoms.^{6Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 164.} ACSM gives these worked examples:^{7Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 144.},^{8Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 145.}

Client	Exercises regularly?	Known disease?	Symptoms?	Wants	Clearance needed?
50, walks 3 days a week, past heart attack	Yes	Yes	No	Vigorous	Yes
22, new gym member, sedentary office job	No	No	No	Moderate	No
45, lifelong triathlete, chest tightness on exertion	Yes	No	Yes	Vigorous	Yes
60, coronary stent, inactive since rehab	No	Yes	No	Moderate	Yes
35, training for a long ride, takes a statin	Yes	No	No	Vigorous	No

A client with symptoms needs clearance, even if they’re a trained triathlete. Known disease in someone who isn’t exercising means clearance before even moderate work. And a risk factor alone, like the 35-year-old’s high cholesterol, doesn’t trigger referral.

Healthy but sedentary clients don’t need clearance, but they should start at light intensity and build to moderate, ideally over a “progressive transitional phase” of about 2–3 months, as long as they stay symptom-free.^{9Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 132.} ACSM also notes the algorithm was built around endurance exercise. Evidence on cardiac screening for resistance training is limited, but that risk appears low.^{10Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 137.}

If a client develops symptoms after starting, re-screen and refer.^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.}

What does medical clearance for exercise mean?

Clearance means approval from a health care provider to exercise.^{6Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 164.} What the evaluation involves is the provider’s call. It might be a conversation, an ECG or other tests, and ACSM doesn’t require an exercise test as part of it.^{1Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 131.},^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.} You can ask for written clearance with any restrictions, such as an intensity limit.^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.} NSCA’s textbook includes a physician’s referral form that asks about conditions exercise might worsen, current medications and program recommendations.^{11Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 167.} Clearance gives you information you need to train the client safely.^{11Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 167.}

How this differs from older risk-factor screening

Older screening counted cardiovascular risk factors such as age, family history, blood pressure and cholesterol. One 2024 trainer textbook still teaches that version: low risk with one risk factor or fewer, moderate with two, high with more than two or any symptoms, and physician approval for vigorous exercise from “moderate risk” upward.^{12International Personal Trainer Academy, Certified Personal Trainer Textbook, p. 150.}

ACSM dropped risk-factor counting from the clearance decision. Risk factors are so common, and exercise-related cardiac events so rare, that counting them predicts little. It also generates a lot of unnecessary referrals, especially in adults over 40.^{9Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 132.} ACSM still recommends assessing risk factors and sharing them with the client and their provider. They no longer decide clearance on their own.^{9Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 132.} Where an older form and the current ACSM algorithm disagree, use the current ACSM algorithm.

What is the PAR-Q+ and how do trainers use it?

The PAR-Q+ is a self-screening questionnaire: seven general health questions, with follow-ups for anyone who answers yes. It was designed partly to cut false positives and needless barriers to exercise. Clients can use it on their own, and trainers can use it alongside the ACSM algorithm. Some clients need help completing it, so go through the answers with them.^{8Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 145.}

The older rule was that any “yes” means seeing a doctor first, and some textbooks still teach it.^{13International Personal Trainer Academy, Certified Personal Trainer Textbook, p. 146.},^{14Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 166.} The current form routes “yes” answers through condition-specific follow-ups instead. If any follow-up is also a yes, the client should get more information first, via the online ePARmed-X+ or a qualified exercise professional.^{15Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 179.} The form also specifies:

• Delay more activity during a temporary illness like a cold or fever.^{15Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 179.}
• Talk to a health care practitioner before becoming more active during pregnancy.^{15Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 179.} (See exercise during pregnancy and postpartum.)
• A completed form is valid for up to 12 months and becomes invalid if the client’s condition changes.^{16Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 177.}

The PAR-Q+ assesses whether exercise is safe. It doesn’t measure cardiovascular risk or fully capture risk factors, medications or contraindications, so pair it with a fuller health history.^{17Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 155.}

What should a personal trainer’s intake form include?

A health and medical questionnaire fills those gaps. NSCA’s sample asks about:^{18Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 182.}

• Medical and family history: past and current conditions, recent operations, and heart disease, high blood pressure or diabetes in close relatives.
• Medications, including beta-blockers, which change heart rate responses and affect test results.^{19Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 169.}
• Injuries that may interfere with exercise.
• Training history: current exercise, past resistance training, any previous trainer.
• Smoking, weight history and eating habits.
• Goals, listed in order of priority.

The initial interview also covers goals in more depth. NSCA recommends SMART goals: specific, measurable, action-oriented, realistic and time-sensitive.^{20Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 154.} A fuller history can also turn up conditions the screening algorithm doesn’t cover, which may still warrant referral.^{21Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 148.}

When to test fitness

NSCA says to assess fitness only after a thorough screening and, where needed, a physician’s recommendations.^{22Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 201.} There’s no standard test battery. Choose tests based on the client’s health, goals and your own experience.^{23Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 190.}

When you do test:

• Take resting measures first: heart rate, blood pressure, height, weight and body composition.^{19Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 169.}
• For general fitness, NSCA suggests non-fatiguing tests like flexibility and balance, then strength, then muscular endurance, then a submaximal aerobic test.^{24Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 203.}
• Give pretest instructions, such as 6–8 hours of sleep the night before.^{22Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 201.}
• Use movement screens, such as a single-leg squat or forward step-down, to assess movement quality at the hip, knee and ankle.^{25NSCA’s Essentials of Personal Training, Third Edition, pp. 256–257.}

Serious complications during maximal exercise tests in apparently healthy people are rare: 0.2–0.8 deaths and 1.4 non-fatal events per 10,000 tests. Submaximal tests likely carry even less risk, though there’s no data on it.^{8Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 145.}

Hold off on exertional testing while a client is waiting for clearance. NSCA suggests using the wait for goal setting, talking through readiness to change, and building habits that help them stick with a program.^{26Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 200.}

When to refer to a physician

Refer when:

• The screening points to medical clearance.
• New symptoms appear after the client starts training.^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.}
• A client returns from an injury or illness. The NSCA’s standards call for documented clearance before they come back.^{27National Strength and Conditioning Association, NSCA Strength and Conditioning Professional Standards and Guidelines, p. 4.}
• The issue is outside your scope, such as diagnosing or treating a medical condition.^{3Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 677.}
• A client has a disease affected by diet and needs medical nutrition therapy, which falls to a licensed nutritionist, dietitian or registered dietitian, depending on local licensure law.^{28NSCA’s Essentials of Personal Training, Third Edition, p. 118.}

Documentation and informed consent

Informed consent describes the program, its risks and benefits, confidentiality, and the client’s responsibilities, and records that the client accepts them. Go through it verbally and in writing before any testing or training.^{29Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 156.}

Waivers and assumption-of-risk forms may limit liability, but their legal force is unclear and depends on how courts interpret them.^{29Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 156.} Laws vary from state to state, and NSCA advises against using any form without individual legal advice.^{30Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 691.}

Keep screening and medical clearance documents, return-to-participation clearances, injury and incident reports, and training logs.^{31National Strength and Conditioning Association, NSCA Strength and Conditioning Professional Standards and Guidelines, p. 7.} Store them securely with limited access. Statutes of limitations vary, so keep files as long as possible or ask a lawyer.^{31National Strength and Conditioning Association, NSCA Strength and Conditioning Professional Standards and Guidelines, p. 7.}

Pre-participation screening checklist for new clients

1. Before the first session, collect the intake packet: PAR-Q+ and a fuller health history questionnaire.^{17Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 155.}
2. Work through ACSM’s four questions and follow up on vague answers.
3. If clearance is needed, refer and ask for written clearance with any restrictions. Use the waiting time for goals and habits.
4. Note risk factors and medications. Share risk factors with the client and their provider.
5. Get informed consent signed, plus any waiver, after checking local law.
6. Test only what you need, taking resting measures first. Start sedentary clients at light intensity.
7. Re-screen when symptoms appear, after illness or injury, and at least yearly.

Common questions

Does every new client need a doctor’s note?

No. Under the ACSM algorithm, healthy clients with no symptoms don’t need medical clearance. That includes people who don’t currently exercise, as long as they start light and progress gradually.^{8Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 145.},^{9Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 132.} Clearance is reserved for clients with symptoms, or with known disease, depending on their activity level and planned intensity.

Is high blood pressure a reason to require clearance?

It depends on the reading. In the screening algorithm, ACSM treats hypertension as a risk factor, not heart disease.^{4Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 140.} But ACSM also says clients whose blood pressure isn’t controlled (130/80 mmHg or higher at rest) should consult their health care provider. That doesn’t necessarily rule out light to moderate activity.^{32Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 679.} NSCA’s textbook is more cautious and lists hypertension among conditions of primary concern.^{2Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 675.} For clients with high blood pressure, the PAR-Q+ follow-ups ask whether it’s hard to control and whether it’s 160/90 mmHg or higher at rest.^{33Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 178.}

How often should I re-screen a client?

A completed PAR-Q+ is valid for up to 12 months and becomes invalid if the client’s condition changes.^{16Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 177.} New symptoms, a new diagnosis, or a return from injury or illness are all reasons to screen again.^{5Ozemek et al., ACSM’s Guidelines for Exercise Testing and Prescription, 12th ed., p. 141.},^{27National Strength and Conditioning Association, NSCA Strength and Conditioning Professional Standards and Guidelines, p. 4.}

Can I run fitness tests in the first session?

Yes, once screening is complete and the client doesn’t need clearance.^{22Schoenfeld and Snarr (eds.), NSCA’s Essentials of Personal Training, 3rd ed., p. 201.} For a new or deconditioned client, choose submaximal tests that match their goals.