Name *

First Name

Last Name

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 your chest when you do physical activity? *

Yes

No

In the past month, have you 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? *

Yes

No

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *

Yes

No

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

Yes

No

Do you know of any other reason why you should not do physical activity? *

Yes

No