Physical Activity Readiness Questionnaire

GENERAL HEALTH QUESTIONS

First Name

Last Name

Please read the 7 questons below carefully and answer each one honestly: Check YES or No

1 ) Have your doctor ever said that you have a heart condition or high blood pressure?

Yes No

2 ) Do you feel pain in your chest at rest, during your daily activities of living OR when you do physical activity?

Yes No

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).

Yes No

4) Have you ever been diagnosed with another chronic medical condition? (other than heart disease or high blood pressure

Yes No

PLEASE LIST CONDITIONS HERE:

5) Are you currently taking prescribed medications for chornic medical condition?

Yes NO

PLEASE LIST CONDITIONS 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?

Yes NO

Please answer NO if you had in the past, but it doens't limit your current ability to be physically active. PLEASER LIST CONDITIONS HERE:

7) Has your doctor ever said that you should only do medically supervised physical activity?

Yes No

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the PARTICIPANT DECLARATION. If you answerned yes to any questions please consult with your physician.

PARTICIPANT DECLARATION

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian or care provider must also sign this form. I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire, I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my conditionchanges. I also acknowledge that Simetre Fitness may retain a copy of this form for its records. In these instances,it will maintain the confifentiality of the same, complying with applicable law.

Name

Signature

Clear

Date