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

Yes

No

2. Have you ever experienced unexplained chest pain during activity or at rest? *

Yes

No

3. Do you lose balance because of dizziness or lose consciousness? *

Yes

No

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

Yes

No

5. Is your doctor currently prescribing medication for your blood pressure or heart condition, or other serious illness? *

Yes

No

6. Are you pregnant or have given birth in the last three months? *

Yes

No

7. Do you know of any other reason why you should not do physical activity? (e.g. uncontrolled diabetes or epilepsy) *

Yes

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. *

Agree