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Physical Activity Readiness Form 2023
Physical Activity Readiness Form
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* Indicates required question
Email
*
Your email
Name
Your answer
Date of Birth
Your answer
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by the doctor?
Yes
No
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Do you feel chest pain when engaged in physical activity?
*
Yes
No
In the past month have you had chest pain when you ARE NOT engaged in physical activity?
Yes
No
Clear selection
Do you ever lose balance because of Dizziness or do you ever lose consciousness?
Yes
No
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Do you have a bone or joint problem which could be made worse by engaging in physical activity?
Yes
No
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If answered yes to previous question please give details....
Your answer
Is your Doctor currently prescribing drugs for blood pressure or a heart condition?
Yes
No
Clear selection
If answered yes to previous question please give details....
Your answer
Have you undergone any surgery which would impact your ability to engage in physical activity?
Yes
No
Clear selection
If answered yes to previous question please give details....
Your answer
Do you know of any other reason why you should not participate in physical activity?
Yes
No
Clear selection
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