Name *

First Name

Last Name

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

Yes

No

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

Yes

No

In the past month, have you had any chest pain when NOT performing physical activity? *

Yes

No

Do you ever 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 you any medication for blood pressure or a heart condition? *

Yes

No

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

Yes

No