Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred medium of communication *

Phone call

Text message

Email

Medical history *

If you don't suffer from any of the below diseases, write none in the "other:" field

Diabetes

High blood pressure

Multiple sclerosis

Arthritis

Back pain

Headaches

Muscle spasms

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when you do physical activity? In the past month, have you had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness? *

Yes

Now

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

Yes

No

In the past month, have you had chest pain when you were not doing physical activity?

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes

No

Do you know of any other reason why you should not do physical activity?

Yes

No