|DOB||Age||Home Phone||Work Phone|
Regular exercise is associated with many health benefits. Increasing physical activity is safe for most people. However, some individuals should check with a physician before they become more physically active. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly:
|Yes||No||1) Has a physician ever diagnosed you with a heart condition and indicated you should restrict your physical activity?|
|Yes||No||2) When you perform physical activity, do you feel pain in your chest?|
|Yes||No||3) When you were not engaging in physical activity, have you experienced chest pain in the past month?|
|Yes||No||4) Do you ever faint or get dizzy and lose your balance?|
|Yes||No||5) Do you have an injury or orthopedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity?|
|Yes||No||6) Do you have high blood pressure or a heart condition in which a physician is currently prescribing a medication?|
|Yes||No||7) Are you pregnant?|
|Yes||No||8) Do you have insulin dependent diabetes?|
|Yes||No||9) Are you 69 years of age or older and not used to being very active?|
|Yes||No||10) Do you know of any other reason you should not exercise or increase your physical activity?|
If you answered yes to any of the above questions, talk with your doctor before you become more physically active. Tell your doctor your plan to exercise and to which questions you answer yes.
If you honestly answered no to all questions you can be reasonably certain you can safely increase your level of physical activity gradually.
If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.