Name *

First Name

Last Name

Phone Number *

(###)

###

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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

Do you feel pain in your chest when you perform physical activity? *

Yes

No

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

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 any medication for your blood pressure or for a heart condition? *

Yes

No

Does your occupation require extended periods of sitting? *

Yes

No

Does your occupation require you to wear shoes with a heel (dress shoes)? *

Yes

No

Does your occupation cause you anxiety (mental stress)? *

Yes

No