Physical Activity and Medical Readiness Form

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*

Do you feel any pain in your chest when you perform physical activity?*

In the past month, have you had chest pain when you were not performing any physical activity?*

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

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

Is your doctor currently prescribing any medications for your blood pressure, or for a heart condition?*

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?*

Does your occupation require repetitive movements?*

Does your occupation require you to wear shoes with a heel?*

Does your occupation cause you mental stress?*

Do you partake in any recreational activities?*

Do you have any additional hobbies?*

Have you ever had any injuries or chronic pain?*

Have you ever had any injuries or chronic pain?*

If yes, please explain

Have you ever had any surgeries?*

If yes, please explain

Has a medical doctor ever diagnosed you with a chronic disease such as heart disease, hypertension, high cholesterol, or diabetes?*

If yes, please explain

Are you currently taking any medication?*

If yes:

Today's Date*