Name *

First Name

Last Name

Date *

MM

DD

YYYY

Phone *

(###)

###

####

Do you have a heart condition in which you should undertake only the kind of physical activity recommended by a physician? *

Yes

No

When undertaking physical activity, do you feel pain in your chest? *

Yes

No

Have you ever experienced chest pain in the past two months while not performing any physical activity? *

Yes

No

Do you ever lose consciousness, balance or feel dizzy? *

Yes

No

Do you have a joint or bone problem that may get worse during physical activity? *

Yes

No

Is a doctor currently prescribing medication to you for high blood pressure or heart condition? *

Yes

No

Are you pregnant? *

Yes

No

Do you know of any reason that you should not increase your physical activity? *

Yes

No