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If you are planning to take part in physical activity or an exercise class, please answer the questions below. If you are between the ages of 15 and 69 the questionnaire will advise you if you should talk to your doctor before you start. If you are over 69 years of age, and you are not used to being very active, we recommend that you consult your doctor first. All information provided will be treated confidentially.
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Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you ever feel pain in your chest when you do physical activity? *
Have you ever had chest pain when you were not doing physical activity? *
Do you ever feel faint or have spells of dizziness? *
Do you have joint problem that could be made worse by exercise? *
Have you ever been told that you have high blood pressure? *
Are you currently taking any medication of which we should be made aware? *
Are you pregnant or have you had a baby in the last six months? *
Is there any other reason why you should not participate in physical activity? *
If you have answered YES to one or more questions;
We recommend that you talk to your doctor by telephone on in person before you start becoming more physically
active and before you have a fitness assessment. Tell your doctor about the questionnaire and which questions(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 to your doctor about the kind of
activity you wish to participate in and follow his or her advice.

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, however remember: begin slowly and build up gradually.
Please note: If you health changes so that subsequently you answer “yes” to any of the above questions, inform one
of our fitness instructors immediately. Ask whether you should change your physical activity or 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.
Full Name (Forename & Surname) *
Date of Birth *
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