Name *

First Name

Last Name

Date of birth

MM

DD

YYYY

Emergency Contact Details

First Name

Last Name

Please answer the questions below. If you are between the ages of 15 and 69, the questions below will tell you whether you need to consult a doctor before becoming more physically active. If you are over 69 and not used to being very active, you should check with your doctor first. *

Has your doctor ever said that you have a heart condition and that you should only take part in physical activity prescribed by them?

Yes

No

*

Do you feel pain in your chest when you take part in physical activity?

Yes

No

*

In the past month, have you had chest pain when you were not being physically active?

Yes

No

*

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

Yes

No

*

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

Yes

No

Is your doctor currently prescribing drugs for high or low blood pressure, or a heart condition?

Yes

No

Do you know of any other reason why you should not take part in physical activity?

Yes

No