physical activity readiness questionnaire
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Name *
Date of Birth *
Email *
Address *
Phone number *
1. Has your doctor ever said that you have a heart condition and recommended only medically supervised activity? *
2. Do you have chest pain brought on by physical activity? *
3. Have you developed chest pains in the last month *
4. Do you tend to lose consciousness or fall over as a result of dizziness? *
5. Do you have a bone/ joint problem or previous injury that could be aggravated by the proposed physical activity? *
6. Has a doctor ever recommended medication for blood pressure or a heart condition or do you take medication? *
7. Are you pregnant or have you been pregnant in the last 3 months? *
8. Do you know, through you own experience, or doctor’s advice, of any other physical reason why you should not exercise without medical supervision? *
If you answered YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
If you answered NO to ALL of the questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level.
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