About You

Name: Address:

City: State: Zip:

Email: Phone: Second Phone:

Emergency Phone:

Dr. Name: Dr. Phone:

Gender: Male Female Age: Height:

Physical Activity Readiness Questionnaire

1. Has a doctor ever said you have heart trouble? Yes No

2. Do you frequently suffer from pains in your chest? Yes No

3. Do you often feel faint or have spells of severe dizziness? Yes No

4. Has a doctor ever told you that your blood pressure was too high? Yes No

5. Do you have a bone or joint problem that could be made worse by a change in your

physical activity?   Yes No

6. Do you know of any other reason why you should not engage in a physical activity? Yes No

7. Are you over the age of 65 and not accustomed to vigorous exercise? Yes No

8. Have you consulted your physician regarding increasing your physical activity and/or having

a fitness evaluation?  Yes No

 9. Heart condition? Yes No   10. Diabetes? Yes No   11. Asthma? Yes No  12. Arthritis?  Yes No

 13. Hernia? Yes No   14. Recent surgery? Yes No  15. High Cholesterol? Yes No

16. Knee Problems? Yes No   17. Back Problems? Yes No

18. Please list any medications/supplements you are currently taking (e.g. birth control, diet pills,

aspirin, prescription medications etc.) and dosage and reason for taking if appropriate.

By submitting this form I am certifying that the above statements are true and correct.