Name *

First Name

Last Name

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

Yes

No

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

Yes

No

In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance from dizziness or lose consciousness? *

Yes

No

Do you have a bone or joint problem that could be made worse by physical activity? *

Yes

No

Is your doctor prescribing drugs for your blood pressure or heart condition, or are you taking any other medication that could be affected by physical activity? *

Yes

No

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

Yes

No

I have read and understood all the questions above *

Yes

No

I have answered all the questions to the best of my knowledge *

Yes

No

Please write your full name as a signature and the box below *

First Name

Last Name