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Name (First Last)
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Your answer
Gender
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Male
Female
Email
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Your answer
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?
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Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
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Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
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Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
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Yes
No
Do you know of any other reason why you should not do physical activity?
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Yes
No
If you answered yes to any of the above please explain in the text box below.
Your answer
If you are receiving course credit for your participation, please indicate from which course you are coming and your instructor (e.g., KIN220, Larson)
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Your answer
Please list the name of 3-5 same gender friends that you know and like that would be interested in participating in the study. (We may look up their names to contact them for participation)
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Your answer
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