Name *

First Name

Last Name

Phone

(###)

###

####

Has your doctor ever said that you have a heart condition and that you YES/NO should only do physical activity recommended by a doctor?

YES

NO

Do you ever feel pain in your chest when you do physical activity?

YES

NO

Have you ever 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/feel faint?

YES

NO

Are you currently taking any medication that your instructor should be made aware of?

YES

NO

Do you have a joint or back problem which could be made worse by exercise?

YES

NO

Are you pregnant or have you had a baby in the last 6 months?

YES

NO

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

YES

NO

I have read, understood and completed this questionnaire to the best of my knowledge. *

YES