Physical Activity and Medical Readiness Form Step 1 of 2 50% Name* First Last Age*Height* Weight* HR: BP at last Physical Date of last Physical MM slash DD slash YYYY Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?* Yes No Do you feel any pain in your chest when you perform physical activity?* Yes No In the past month, have you had chest pain when you were not performing any 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 a change in your physical activity?* Yes No Is your doctor currently prescribing any medications for your blood pressure, or for a heart condition?* Yes No Do you know of any other reason why you should not engage in physical activity?What is your current occupation?* Does your occupation require extended periods of sitting?* Yes No Does your occupation require repetitive movements?* Yes No Does your occupation require you to wear shoes with a heel?* Yes No Does your occupation cause you mental stress?* Yes No Do you partake in any recreational activities?*Do you have any additional hobbies?*Have you ever had any injuries or chronic pain?* Yes No Have you ever had any injuries or chronic pain?* Yes No If yes, please explainHave you ever had any surgeries?* Yes No If yes, please explainHas a medical doctor ever diagnosed you with a chronic disease such as heart disease, hypertension, high cholesterol, or diabetes?* Yes No If yes, please explain Are you currently taking any medication?* Yes No If yes:Today's Date* MM slash DD slash YYYY Δ