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Name
DOB
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Email
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Are you below the age of 15 or over the age of 69?
Yes
No
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 were 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 example, water pills) for your blood pressure or heart condition?
Yes
No
Do you know of any other reason why you should not do physical activity?
Yes
No
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