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Physical Activity Readiness Questionnaire

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months? *

Yes

Are you currently suffering from a medical condition, illness, or injury? *

Yes

Has your doctor ever said that you have a heart condition and that you should only perfom physical ativity recommended by a doctor? *

Yes

Do you feel pain in your chest when you perform physical activity? *

Yes

In the past month, have you had chest pain when you are not performing any physical activity? *

Yes

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

Yes

Do you have a bone or joint problem that could be made worst by a change in your physical activity? *

Yes

Is your doctor currently prescribing any medication for your blod pressure or for a heart condition? *

Yes

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

Yes

If you answered yes to one or more of the above questions, consult your physician before engaging in physical activity. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

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