Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *

YES

NO

Do you feel pain in your chest when you do physical activity?Checkbox 1 *

YES

NO

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

YES

NO

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

YES

NO

Do you have a bone or joint problem ( for example back, knee or hip) that could be made worse by a change in your physical activity? *

YES

NO

Is your doctor currently prescribing medication for your blood pressure or heart condition? *

YES

NO

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

YES

NO