Physical Activity and Medical Questionnaire 

Name *
Name
Date of Birth *
Date of Birth
Phone
Phone
Has a doctor ever said you have a heart condition and can only perform physical activity recommended by a doctor? *
Do you feel pain in your chest when you perform physical activity? *
In the past month, have you had chest pain when you were not performing physical any activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Has a doctor ever said your blood pressure is too high? *
Do you have a bone or joint problem that could be made worse by a change physical activity? *
Is your doctor currently prescribing any medication for your blood pressure or heart a condition? *
Are you over the age of 65 and not accustomed to vigorous exercise? *
Are you aware, through your own experience or a doctor' advice, of any other reason not mentioned here why you should not follow physical activity? *
If yes, please explain.
Do you currently have or have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?
If yes, please explain.
Have you ever had any surgeries?
If yes, please explain.
Has a medical doctor ever diagnosed you with any of the following conditions and chronic diseases? *
If yes, please explain.
Are you currently pregnant, or were in the past three months? *
Are you currently taking any medication? *
If yes, please list.
Please sign below. Typing your name serves as your signature

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