Name
*
First Name
Last Name
1. Has your doctor ever told you have a heart condition and require only supervised activity?
*
Yes
No
If yes, please explain...
2. Do you have pains in your heart or chest?
*
Yes
No
If yes, please explain...
3. Do you often feel faint or have spells of dizziness?
*
Yes
No
If yes, please explain...
4. Has a doctor ever told you that your blood pressure was too high?
*
Yes
No
If yes, please explain...
5. Has your doctor ever told you that you have a joint or bone problem, such as arthritis, that can be aggravated by exercise?
*
Yes
No
If yes, please explain...
6. Do you have back or neck problems?
*
Yes
No
If yes, please explain...
7. Are there any other physical or psychological reasons not mentioned here why you should not follow an activity program if you wanted to?
*
Yes
No
If yes, please explain...
8. Are you over the age of 65 and not accustomed to physical exercise?
*
Yes
No