Physical Activity Readiness Questionnaire

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If you are between the ages of 15 and 69 this questionnaire will tell you if you need to check with your doctor before you start this exercise class. If you are over 69 years of age, and you are not used to being active, check with your doctor before you start. All information will be treated confidentially.

Name:

email address:

1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

yes

2. Do you ever feel pain in your chest when you do physical activity?

yes

3. Have you ever had chest pain when you were not doing physical activity?

yes

4. Do you ever feel faint or have spells of dizziness?

yes

5. Do you have a joint problem that could be made worse by exercise?

yes

6. Have you ever been told that you have high blood pressure?

yes

7. Are you currently taking any medication which I should be made aware of? If yes, what?

yes

If yes. The medication that I am taking is:

8. Are you pregnant or have you had a baby in the last six months?

yes

9. Is there any other reason why you should not participate in physical activity? If yes, what?

yes

If yes. A reason why I should not participate is:

If you have answered ‘YES’ to one or more questions. Talk to your doctor by phone or in person before you start becoming more physically active. Tell your doctor about the questionnaire and which question(s) you answered yes to. You may be able to do any activity you want – as long as you begin slowly and build up gradually, or you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kind of activity you wish to participate in and follow their advice.

will do

N/A

If you have answered ‘NO’ to all questions: You can be reasonably sure that you can start to become more physically active and take part in a suitable exercise programme. Remember – begin slowly and build up gradually. Please note: If your health changes so that subsequently you answer yes to any of the above questions, please inform me immediately as we may need to change your exercise plan. Delay becoming more active if you feel unwell because of a temporary illness such as cold or flu – wait until you are better.

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