Physical Assessment Readiness Questionnaire
Your fitness and health is of top priority to Capoeira Valente and we would love to have you work out and train with us as much as possible. To do so, and to ensure maximum safety is followed, please take the time to answer the following assessment so that we can be better prepared for any eventualities as well as get a better understanding on our students and where we can place emphasis into your training.
Email address *
Name *
Your answer
Height (ft or cm)
Your answer
Weight (optional, but we won't share)
Your answer
Physicians Name
Your answer
Physicians Contact Number
Your answer
Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
A copy of your responses will be emailed to the address you provided.
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