Name *

First Name

Last Name

Has your doctor ever said 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

Do you lose balance because of dizziness or do you ever lose consciousness? *

YES

NO

Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity? *

YES

NO

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

YES

NO

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

YES

NO

Are you currently or have you been pregnant in the last 6 months? *

YES

NO

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date

MM

DD

YYYY