Fill free to complete as much or as little of this form as you like.
Name *
E-mail
Phone
I am looking forI am looking forPrivate TrainingOnline CoachingOn-Demand ProgramsOther
The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is very safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor OR a qualified exercise professional before becoming more physically active.
Please read the 7 questions below carefully and answer each one honestly: Select YES or NO.
1) Has your doctor ever said that you have a heart condition OR high blood pressure?1) Has your doctor ever said that you have a heart condition OR high blood pressure?YESNO
2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? 2) Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity?YESNO
3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).3) Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise).YESNO
4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?4) Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?YESNO
If YES, please list here
5) Are you currently taking prescribed medications for a chronic medical condition?5) Are you currently taking prescribed medications for a chronic medical condition?YESNO
PLEASE LIST CONDITION(S) AND MEDICATIONS HERE:
6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.6) Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer NO if you had a problem in the past, but it does not limit your current ability to be physically active.YESNO
PLEASE LIST CONDITION(S) HERE:
7) Has your doctor ever said that you should only do medically supervised physical activity?7) Has your doctor ever said that you should only do medically supervised physical activity?YESNO
SELECT A GOOD DATE TO CONTACT YOU
BEST TIME TO CALLBEST TIME TO CALL8AM9AM10AM11AM1PM2PM3PM4PM5PM
