Physical Activity Readiness Questionnaire
Please answer all of the questions below
Have you ever been advised by a doctor that you have a heart condition and should only do physical activity recommended by a doctor?
*
YES
NO
Do you ever feel pain in your chest when you perform physical activity?
*
YES
NO
Have you ever had chest pain when you are not doing physical activity?
*
YES
NO
Do you ever feel faint or have spells of dizziness?
*
YES
NO
Do you have bone or joint problems that could be made worse by exercise?
*
YES
NO
Have you ever been told that you have high blood pressure?
*
YES
NO
Are you currently taking any medication?
*
YES
NO
If the above answer is 'YES' then please describe below:
Do you suffer from any allergies?
*
YES
NO
If the above answer is 'YES' then please describe below:
Are you currently or have you been pregnant in the last 6 months?
*
YES
NO
Are there any other reasons not mentioned why you should not exercise?
*
YES
NO
If the above answer is 'YES' then please describe below:
Client Name:
*
Client Date of Birth:
*
Client Full Address:
*
Client Telephone Number:
*
Client Email Address:
*
Emergency Contact Name:
*
Emergency Contact Telephone Number:
*
Current Date:
*
Client Signature:
*
Submit
Should be Empty: