Physical activity readiness questionnaire Section 1

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physical activity readiness questionnaire

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Name

Phone Number

Have you ever been diagnosed with a heart condition or high blood pressure?

YES NO

Please list the condition(s) here:

Have you ever experienced chest pain during rest, routine daily activities, or during physical activity?

YES NO

Have you ever lost balance due to dizziness or loss of consciousness (answer no if symptoms were caused due to hyperventilation associated with intense physical exertion)

YES NO

Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

YES NO

Please list the condition(s) here:

Have you ever suffered or currently suffer from a bone, joint, or soft tissue problem that could be made worse by becoming more physically active? (Answer no if you have had issues in the past, but does not limit currently physical ability)

YES NO

Please list the condition(s) here:

Have you ever had a recommendation to only participate in medically supervised physical activity?

YES NO

I have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that a Trustee (such as my employer, community/fitness centre, health care provider, or other designate) may retain a copy of this form for their records. In these instances, the Trustee will be required to adhere to local, national, and international guidelines regarding the storage of personal health information ensuring that the Trustee maintains the privacy of the information and does not misuse or wrongfully disclose such information.

If you answered NO to all of the questions above, you are cleared for physical activity. You can submit section 1. You do not have to fill out the rest of the form.

Start becoming much more physically active – start slowly and build up gradually.
Follow International Physical Activity Guidelines for your age (www.who.int/dietphysicalactivity/en/).
You may take part in a health and fitness appraisal.
If you are over the age of 45 yr and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualifed exercise professional before engaging in this intensity of exercise.
If you have any further questions, contact a qualifed exercise professional.

continue

If you answered YES to one or more of the questions above, please complete the next section

next - part 2

Whether it be a bodyweight workout, a home workout or a free weight session in the gym. I will create a plan to suit your goals, based around your own personal environment.

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