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Health questionnaire
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Last Name
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Has your doctor ever said that 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
In the past month, have you had chest pain while you were not doing physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem that could be made worse by physical activity?
Yes
No
Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Yes
No
Are you pregnant or recently had a baby?
Yes
No
Have you had any recent injuries or operations?
Yes
No
If yes please give details:
Yes
No
Do you know of any other reason why you should not do physical activity?
Yes
No
I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance training and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.
If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional.
If you answered YES to one or more questions: Talk to your doctor BEFORE you become more physically active or have a fitness appraisal. Discuss with your doctor which kinds of activities you wish to participate in.
I agree
Not applicable
I have taken medical advice and my doctor has agreed that I should exercise.
I agree
Not applicable
I declare that the info I’ve provided is accurate & complete
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