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GENERAL HEALTH QUESTIONS

 

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

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

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

Yes No

PLEASE LIST CONDITIONS HERE:

Are you currently taking prescribed medications for chornic medical condition?

Yes NO

PLEASE LIST CONDITIONS HERE:

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:

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