Physical Activity Readiness Questionnaire
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions below. If you are between the ages of 15 and 69, this will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Delay becoming much more active if you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or if you are or may be pregnant – talk to your doctor. Please read the questions carefully and answer each one honestly:
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
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2. Do you feel pain in your chest when you do physical activity? *
3. In the past month, have you had chest pain when you were not doing physical activity? *
4. Do you lose your balance because of dizziness or do you ever lose consciousness? *
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *
7. Do you know of any other reason why you should not do physical activity?
If Yes, Please Explain
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Did you answer YES to one or more questions above? *
Your Name: *
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Your Phone Number: *
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Your Email Address:
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Emergency Contact Name: *
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Emergency Contact Phone Number:
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