Alexander

This is an industry-standard form used to help determine if you should consult with healthcare providers before becoming more physically active. Please read and answer the following questions honestly.

1. Do you know if you have any heart conditions?

2. Do you frequently experience chest pain when you do physical activity?

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

4. Do you lose balance due to dizziness or have you lost consciousness?

5. Do you have a joint or bone problem that could be made worse by physical activity?

6. Are you currently taking prescription drugs?

7. Are you currently under medical advice recommending restrictions with exercise?

8. Do you suspect or know of any reason you should seek medical advice before participating in exercise?

If you answered “Yes” to one or more questions, consult with your doctor or other healthcare provider before engaging in physical activity. If you answered “No” to all questions, you can likely engage in physical activity but should still consult with healthcare providers if you have concerns or experience discomfort.