Participant Activity Readiness Questionnaire Name * First Name Last Name Email * Phone * (###) ### #### Are you currently taking any medications that may be relevant to physical activity? (please list all medications if 'yes') * Do you have any current or past injuries/surgeries which may be relevant to physical activity? * Do you experience an irregular or racing heart rate during rest or exercise? * Have you ever had a heart condition and should only do physical activity recommended by a doctor? * Do you feel pain in your chest when you engage in physical activity? * Is your doctor currently prescribing you medication for a blood pressure or heart condition? * Do you lose your balance because of dizziness or do you ever lose consciousness? * Have you ever been diagnosed with a specific medical condition? (onset date, treatment, physician clearance) * Do you have a bone or joint problem that could be made worse by a change in your physical activity? * Are you over the age of 65 and not accustomed to vigorous exercise? * Are you diabetic? * Are you pregnant? Or planning? * Do you know any reasons why you should NOT participate in physical activity? * Thank you!
