Exercise Readiness Questionnaire
We have been made aware of the many benefits that regular exercise offers and filling in
this questionnaire will help you take one of the first sensible steps into your exercise
programme.
For the vast majority of adults, partaking in physical activity should not pose any
problem or hazard to health. This short questionnaire has been designed to identify the
small number of people for whom physical activity might be inappropriate or those who
should receive medical advice regarding the type of activity most suitable for them.
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Email *
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Best Contact telephone number *
Emergency Contact (name and mobile number) *
Todays Date *
MM
/
DD
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YYYY
What fitness or health goals do you have?
Have you been pregnant or given birth in the past 6 months? *
Has your Doctor ever said you have heart trouble? *
 Do you often feel faint or have dizzy spells? *
 Do you have high blood pressure? *
Do you have any joint or bone problem such as Arthritis that has been aggravated by exercise or physical activity? *
Have you undertaken any surgical procedure recently? *
Do you have any breathing problems such as Asthma? *
Are you Diabetic? *
Are you currently taking any other form of medication, such as Beta Blockers, anti-inflammatory or pain killers? *
Is there any other reason not mentioned here why you should not follow any form of physical exercise activity? *
Has any exercise method (stretching, strength, aerobic, sport) caused a medical problem / injury in the past? *
Details of ANY questions answered Yes above:
If you answered NO to all questions & answered accurately, you have reasonable assurance of your suitability for physical activity participation. If you answered YES to one or more of the questions, it is recommended that you consult your Doctor before partaking in physical activity. If, however you answered YES to one or more questions and you choose to continue with an exercise programme you should understand your waiving of any legal recourse for damages to yourself arising from your activities. Improper use or non-prescribed use of equipment against advice and any resulting injury to yourself results in your waiving of any legal recourse arising from such activities.
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