Name *

First Name

Last Name

Phone Number *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Emergency Contact Number *

(###)

###

####

1. Has your doctor ever said that you have a heart condition or recommended only medically supervised physical activity? *

Yes

No

2. Do you feel pain in your chest when you engage in physical activity? *

Yes

No

3. In the past month, have you had chest pain when not doing physical activity? *

Yes

No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes

No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

7. Do you know of any other reason why you should not do physical activity? *

Yes

No

8. Are you female and currently pregnant or have you given birth in the last 6 months?

(If yes, please note that some activities may need to be adapted due to contraindications)

Yes

No

9. How often do you currently engage in physical activity? *

Never

Occasionally

Regularly (3-4 times per week)

Frequently (5+ times per week)

10. What types of physical activities do you currently participate in? *

(Check all that apply)

Walking

Running/Jogging

Cycling

Weight Training

Yoga/Pilates

Group Fitness Classes

11. Do you smoke or have you recently quit smoking? *

Yes

No

12. Do you have any dietary restrictions or special nutritional needs? *

Yes

No

13. Do you have any allergies? *

(including medication, food, or environmental)

Yes

No

14. Are you currently taking any medications, supplements, or herbal remedies? *

Yes

No

15. Do you have any chronic illnesses or conditions? *

(e.g. diabetes, asthma, epilepsy)

Yes

No

16. Have you had any surgeries or injuries in the past year that could affect your ability to exercise? *

Yes

No

Date *

MM

DD

YYYY