Name

First Name

Last Name

Date Of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has your doctor ever said 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 a chest pain when you were not doing physical activity?

YES

NO

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

YES

NO

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity?

YES

NO

Is your doctor currently prescribing medication for your blood pressure or heart condition?

YES

NO

Do you know of any other reason why you should not take part in physical activity?

YES

NO

Name

First Name

Last Name

Date

MM

DD

YYYY

Name

First Name

Last Name

Date

MM

DD

YYYY