Please provide your contact information for clinic organizers to reach you if needed if they have questions regarding this form.
Your answer
Are you currently seeing a doctor for a recently diagnosed medical condition? (in the last 12 months)
Your answer
Has your doctor ever said that you have a heart condition AND that you should only do physical activity recommended by a doctor? *
Do you feel pain in your chest when you do physical activity? *
In the past month have you had chest pain when you are not doing physical activity?
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Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Are you currently on medication for blood pressure regulation or for a heart condition?
Your answer
Are you aware of any other reason why you should NOT do physical activity? *
Required
Please use this area to expand on any health or fitness conditions you would like to clinic organizers to be aware of. If you answered YES to any of the above questions please describe in more detail as to why you answered YES.
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"I have read understood and completed the questionnaire.By selecting 'Agree' it will act as my signature.
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What is today's date? *
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