Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
—Please choose an option—YesNo
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
What is your current occupation?
Does your occupation require extended periods of sitting?
Does your occupation require extended periods of repetitive movements? If yes, detail below
Does your occupation require you to wear shoes with a heel (dress shoes)?
Does your occupation cause you anxiety (mental stress)?
Do you partake in any recreational activities (golf, tennis, skiing, etc.)? If yes, detail below
Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? If yes, detail below
Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? If yes, detail below
Have you ever had any surgeries? If yes, detail below
Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? If yes, detail below
Are you currently taking any medication? If yes, detail below
