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're not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness, or do you ever lose consciousness? *

Yes

No

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

Yes

No

Is your doctor currently prescribing drugs for blood pressure or a heart condition? *

Yes

No

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

Yes

No

Date *

MM

DD

YYYY