Name

First Name

Last Name

Date *

MM

DD

YYYY

Emergency Contact (In case of emergency, please contact) *

First Name

Last Name

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke and that you should only perform physical activity recommended by a doctor? *

Yes

No

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

Yes

No

Do you ever feel faint, dizzy, lose balance or lose consciousness during physical activity/exercise? *

Yes

No

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes

No

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months? *

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

No

Are you pregnant or have you given birth within the last 12 months? *

Yes

No

Describe your current physical activity/exercise levels in a typical week by stating the frequency and duration at the different intensities. *

INTENSITY

Light

Moderate

Vigorous/High

*

FREQUENCY (number of sessions per week)

1 - 2 per week

3 - 4 per week

5 - 7 per week

*

DURATION (total minutes per week)

0 - 20 minutes

0 - 45 minutes

60 minutes +