Physical Activity Readiness Questionnaire
If you are planning to take part in physical activity or an exercise class, start by answering the questions below. If you are aged between the ages of 15 and 69 the questionnaire will tell you if you should consult with your doctor before you start. If you are over 69 years of age, and are not used to being very active, check with your doctor. Jenny Coppock does not hold any responsibility for medical issues that occur if you decide to continue with any exercise, session, plan or assessment without consulting your doctor first.
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Email *
Client Name *
Date of birth
*
Telephone Number
*
Next of Kin
*
Next of Kin Contact Number
*
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
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Have you ever had chest pain when you were not doing physical activity
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Do you ever feel faint or have spells of dizziness
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Do you have a joint problem that could be made worse by exercise
*
Have you ever been told that you have high blood pressure
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Are you currently taking any medication of which your trainer/coach should be made aware
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Yes/No, please provide information of medication if the answer is Yes.
Are you pregnant or have you had a baby in the last six months
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Is there any other reason why you should not participate in physical activity
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Yes/No, please provide information of reasons why if the answer is Yes.
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 and before you have a fitness assessment. 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. 
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,
My decision
*
A copy of your responses will be emailed to the address you provided.
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