PERSONAL INFORMATION
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Date Of Birth :
Emergency Contact Number:
OTHER DETAILS
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MEDICAL CONDITION
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Has your doctor ever said that you have a heart condition and that you should notonly 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 were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciouness?
Do you have a bone or joint problem (for example, back knee, hip) that could be made worse by change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
