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Ealing Adult Learning                                                                                                                                    Physical Activity Checklist
The following questions are to ensure you are ready to take part in a fitness class.  If you are between the ages of 19 and 69, this questionnaire will tell you whether you should check with a doctor before starting this course.  If you are over 69 and not used to exercise, you should consult your doctor first.

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Are you a complete beginner to exercise? *
Required
Do you have a heart condition? *
Required
Do you ever feel pain in your chest when you do a physical activity? *
Required
Do you ever feel faint or have spells of dizziness/ever lost consciousness? *
Required
Do you have a joint problem that could be made worse by movement? *
Required
Are you currently taking medication that the tutor needs to be aware of? *
Required
Do you have high blood pressure? *
Required
Are you pregnant or have you had a baby in the last 6 months? *
Required
Have you had surgery in the last 12 months? *
Required
Do you have any metal plates, rods, pins or hip, knee replacements etc? *
Required
Is there any other reason why you should not take part in a fitness class? *
Required
If you have answered yes to one or more questions, talk to your doctor before you begin a fitness class.  You must tell the tutor about aspects of the class which will need to be adapted for you, or, you may not be ready to undertake a fitness class at the moment.If you have answered no to all questions, you can begin participating in a fitness class. Your tutor may require written confirmation from your doctor and will advise you if this is the case.
Do you have a hearing impairment that may affect you in a fitness class? *
Required
Do you have a visual impairment that may affect you in a fitness class? *
Required
Do you have a physical disability that may affect you in a fitness class? *
Required
I declare that to the best of my knowledge the above information is correct and that I enter into this programme fully aware of the above ‘at risk’ groups.  I will proceed with caution during the course and will work within my own limits.I will advise the tutor immediately if there is any change in these circumstances. *
Required
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