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Health Risk Appraisal and Risk Stratification

Health Risk Appraisal and Risk Stratification | American Council on Exercise | Exam Preparation Blog | 11/5/2012


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fitness assessmentFitness professionals must be well versed in the Health Risk Appraisal for their clients, which is a systematic screening that addresses signs and symptoms of disease, risk factors and family history.

There are many forms that trainers can and should use on a regular basis when working with clients, some of which should be filled out by the client and reviewed by the trainer during the first few interviews and when there is an agreement to proceed with training.

PAR-Q & You Form

The PAR-Q & You form is recognized as a minimal, yet safe and effective, pre-exercise screening measure for low-to-moderate exercise training. While the questionnaire is broad and may overlook important health information about the individual, it is quick, easy and non-invasive. If the client answers "yes" to any of the questions on the form, the trainer is required to obtain a Health Care Provider's Consent form (also known as Medical Release form). The trainer also needs to have the client sign the Informed Consent and Release of Liability forms, which often are combined into a single form.

There are a host of other forms that may or may not be required by the trainer, including Orthopedic History, Nutritional Profile, Past and Current Activity History, and Exercise Attitude Questionnaire. When used in conjunction with the ACE Integrated Fitness Training Model, these forms can help fine-tune the goals agreed upon by the trainer and client.

Information drawn from the health-appraisal screening can help identify the presence or absence of cardiovascular, pulmonary and other diseases. It also helps to identify individuals with contraindications that would exclude them from physical activity, and detect at-risk individuals who need a medical evaluation before engaging in a fitness program or who need medical supervision while exercising. Additionally, the trainer may need to make recommendations for lifestyle modification and other strategies for exercise testing and exercise prescription based on the information gathered in the screening.

The ACSM Risk Stratification

A more comprehensive risk-factoring process is the American College of Sports Medicine (ACSM) Risk Stratification. While the PAR-Q is acceptable as a self-administered tool without the intervention of the professional community, the ACSM Risk Stratification is generally administered and evaluated by a fitness professional.

Additionally, while the PAR-Q as a quick form with seven basic questions that advises the client to speak to a doctor if they answer yes to one or more the questions (although increased physical activity isn’t necessary contraindicated), the ACSM Risk Stratification tool is more complex and makes recommendations based on what category the client falls into. Risk Stratification is determined by adding up the points as indicated in Table 6-1 on pg. 108 of the ACE Personal Trainer Manual and comparing what actions are recommended based on that score. A score of less than or equal to 1 is considered Low Risk; greater than or equal to 2 is considered Medium Risk; and being symptomatic or having known cardiac, pulmonary or metabolic disease is considered High Risk (reference Figure 6-4 on pg. 109 of the ACE Personal Trainer Manual).

Low-risk individuals may start or continue an unrestricted exercise program without a doctor's advice. Typically, these individuals can exercise at a moderate-to-high intensity level, and can participate in maximal treadmill testing.

Moderate-risk individuals can begin moderate-intensity exercise programs without the advice of a doctor. ACSM defines moderate intensity exercise as 40 to 60% of VO2R (the difference between VO2max and resting VO2) or HRR (heart-rate reserve). ACE recommends that trainers use the VT1 threshold as the upper limit to moderate-intensity exercise. (For information about calculating VT1 (first ventilatory threshold) using the talk test, please refer to page 93 of the ACE Personal Trainer Manual, and the three-zone training model represented in Table 11-9 of Chapter 11, page 392.) Zone 1 in the table refers to moderate-level training, which is exercise within the client's exercise capacity that can be sustained for periods lasting longer than 45 minutes. Moderate-risk individuals should seek a doctor's advice before engaging in high-intensity exercise at greater than 60% of VO2R (Zone 2 in Table 11-9). A doctor's supervision is needed for maximal exercise testing, but is not required for submaximal exercise testing if the client is asymptomatic. Clients who present with symptomatic cardiovascular, pulmonary or metabolic disease must have a doctor's clearance for any level of exercise and will need supervision for maximal and submaximal exercise testing.

To help put this information into practice, consider the following case study:

  • You have a new client named Bill—a 52 year-old male client with no family history of heart disease.
  • Bill weighs 200 pounds, is a non-smoker and works out for an hour in the gym three to four days per week, balancing cardio and strength-training exercise.
  • Bill has a BMI of 22, systolic BP of 130 and diastolic BP of 83.
  • Bill's low-density lipoprotein cholesterol is 175, and high-density lipoprotein cholesterol is 50, with a fasting blood glucose level of 120 mg/dl.

Given these characteristics, what risk category does Bill fall into based on the ACSM Risk Stratification score?


This client has 3 positive risk factors: Age, LDL Cholesterol, and his Fasting Blood Glucose. This would put him in the Moderate Risk Category, which means this client is cleared to participate in moderate-intensity activity, submaximal and maximal exercise tests, but would need physicians clearance if he elected to start with vigorous-intensity activity.