Physical activity readiness questionnaire Section 2

physical activity readiness questionnaire
part 2

Delay becoming more active if:

Name

Phone Number

Upload GP Referral (if required)

1. Do you have Arthritis, Osteoporosis, or Back Problems?

YES NO

If the above condition(s) is/are present, answer questions 1a-1c. If you answered NO, go to question 2

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

YES NO

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

YES NO

2. Do you currently have Cancer of any kind?

YES NO

If the above condition(s) is/are present, answer questions 2a-2b. If you answered NO, go to question 3

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

YES NO

2b. Are you currently receiving cancer therapy (such as chemotheraphy or radiotherapy)?

YES NO

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm

YES NO

If the above condition(s) is/are present, answer questions 3a-3d. If you answered NO, go to question 4

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

3b. Do you have an irregular heart beat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

YES NO

3c. Do you have chronic heart failure?

YES NO

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

YES NO

4. Do you have High Blood Pressure?

YES NO

If the above condition(s) is/are present, answer questions 4a-4b. If you answered NO, go to question 5

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication? (Answer YES if you do not know your resting blood pressure)

YES NO

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

YES NO

If the above condition(s) is/are present, answer questions 5a-5e. If you answered NO, go to question 6

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician- prescribed therapies?

YES NO

5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difculty speaking, weakness, or sleepiness.

YES NO

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

YES NO

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

YES NO

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

YES NO

6. Do you have any Mental Health Problems or Learning Difficulties? This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome.

YES NO

If the above condition(s) is/are present, answer questions 6a-6b. If you answered NO, go to question 7

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

YES NO

7. Do you have a Respiratory Disease? This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure

YES NO

If the above condition(s) is/are present, answer questions 7a-7d. If you answered NO, go to question 8

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

YES NO

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

YES NO

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

YES NO

8. Do you have a Spinal Cord Injury? This includes Tetraplegia and Paraplegia

YES NO

If the above condition(s) is/are present, answer questions 8a-8c. If you answered NO, go to question 9

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

8b. Do you commonly exhibit low resting blood pressure signifcant enough to cause dizziness, light-headedness, and/or fainting?

YES NO

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysrefexia)?

YES NO

9. Have you had a Stroke? This includes Transient Ischaemic Attack (TIA) or Cerebrovascular Event

YES NO

If the above condition(s) is/are present, answer questions 9a-9c. If you answered NO, go to question 10

9a. Do you have difficulties controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

YES NO

9b. Do you have any impairment in walking or mobility?

YES NO

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

YES NO

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?

YES NO

If you have other medical conditions, answer questions 10a-10c. If you answered NO, go to the next step

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

YES NO

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

YES NO

10c. Do you currently live with two or more medical conditions?

YES NO

PLEASE LIST YOUR MEDICAL CONDITION(S) AND ANY RELATED MEDICATIONS HERE:

physical activity readiness questionnaire
part 2

Delay becoming more active if:

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© 2022 Willie Smith Fitness

physical activity readiness questionnairepart 2

Delay becoming more active if:

Navigation

get in touch

physical activity readiness questionnaire
part 2