Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Has your doctor ever said that you have a heart condition and that should only do physical activity recommended by a doctor? *

Yes

No

Do you ever feel pain in your chest when you do physical activity? *

Yes

No

Have you ever had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness/feel faint? *

Yes

No

Are you currently taking any medication that I need to be aware of? *

Yes

No

Do you have a joint or back problem which could be made worse by exercise? *

Yes

No

Are you pregnant or have you had a baby in the last 6 months? *

Yes

No

Do you know of any other reason why you should not participate in physical activity? *

Yes

No

Do you smoke? *

Yes

No

Date

MM

DD

YYYY

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YES