Physical Activity and Medical Questionnaire 

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

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

Yes

No

Do you feel 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 physical any activity? *

Yes

No

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

Yes

No

Has a doctor ever said your blood pressure is too high? *

Yes

No

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

Yes

No

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

Yes

No

Are you over the age of 65 and not accustomed to vigorous exercise? *

Yes

No

Are you aware, through your own experience or a doctor' advice, of any other reason not mentioned here why you should not follow physical activity? *

If yes, please explain.

Yes

No

Do you currently have or have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)?

If yes, please explain.

Yes

No

Have you ever had any surgeries?

If yes, please explain.

Yes

No

Has a medical doctor ever diagnosed you with any of the following conditions and chronic diseases? *

If yes, please explain.

Coronary heart disease

Coronary artery disease

Hypertension (high blood pressure)

High cholesterol

Diabetes

Asthma

Arthritis

Hernia

Sacroiliac Problem

Knee Problems

Back Problems (cervical, thoracic, lumbar)

Recent Injuries

Recent Surgeries

Other (If you suffer from any other condition not listed above, please state below)

None of the above

Are you currently pregnant, or were in the past three months? *

Yes

No

Are you currently taking any medication? *

If yes, please list.

Yes

No