Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone *

(###)

###

####

1. 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

2. Do you feel pain in your chest when you do physical activity? *

YES

NO

3. In the past month, have you had chest pain when you were not doing physical activity? *

YES

NO

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

YES

NO

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

YES

NO

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

YES

NO

Name

First Name

Last Name

Date

MM

DD

YYYY