Physical Activity Readiness Questionnaire

1. Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
 Yes No

2. Do you feel pain in your chest when you perform physical activity?
 Yes No

3. In the past month, have you had chest pain when you were not performing any
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 any medication for your blood pressure or
for a heart condition?
 Yes No

7. Do you know of any other reason why you should not engage in physical
activity?
 Yes No

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntary engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Date:

Your Name:

Your Email:

Telephone number:

Date of Birth:

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