Rivier University HFC Fitness Room Form
Email address *
Name *
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Phone # *
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1. Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? *
2. Do you frequently have pains in your chest when you perform physical activity? *
3. Have you had chest pain when not doing physical activity? *
4. Has a doctor ever said your blood pressure was too high? *
5. Do you have bone or joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program? *
6. Do you lose balance due to dizziness or do you ever lose consciousness? *
7. Have you had a recent surgery? *
8. Have you had any previous injuries we need to be aware about? *
9. Do you have asthma or exercise-induced asthma? *
10. Are you pregnant or have you given birth within the last six months? *
11. Do you know any other reason why you should not do physical activity? *
If you have marked yes to any questions 1-11, please elaborate below:
Your answer
12. Do you take any medications, whether prescription or non-prescription, on a regular basis? If answering yes, please describe what the medication is and how it effects your ability to exercise. *
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13. Do you have any allergies? If answering yes, please list *
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14. If you've answered yes to questions 12 or 13, have you recently consulted with your physician about increasing your physical activity? *
15. If you answered no to question 14, will you agree to consult your physician prior to increasing your physical activity?
Please note:
If your health changes such that you could answer YES to any of the above questions, please inform your trainer/coach/physician. Ask whether you should change your physical activity plan
Signature: By typing my name & today's date below I acknowledge that I have read, understood and completed the questionnaire. Any questions I had were answered to my full satisfaction. *
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A copy of your responses will be emailed to the address you provided.
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