Name *

First Name

Last Name

Have you ever been told that you have a heart condition?

Yes

No

Have you ever had a stroke?

Yes

No

Do you ever have unexplained pains in your chest at rest or during physical exercise?

Yes

No

Do you consistently feel faint or suffer from spells of dizziness?

Yes

No

Do you suffer from asthma and require medication?

Yes

No

Do you suffer from type I or II diabetes?

Yes

No

Do you suffer from any major muscle or joint conditions that may limit you or be aggravated by physical activity?

Yes

No

Do you suffer from any medical conditions that may be made worse by participating in physical activity?

Yes

No

Do you suffer from high blood pressure over 140/90 or low blood pressure below 100/80?

Yes

No

Date

MM

DD

YYYY