Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Has your doctor ever said that you have a heart condition or high blood pressure? *

Yes

No

Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity? *

Yes

No

Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *

Yes

No

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? *

Yes

No

Are you currently taking prescribed medications for a chronic medical condition? *

Yes

No

Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? (Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.) *

Yes

No

Has your doctor ever said that you should only do medically supervised physical activity? *

Yes

No