top of page

Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Has your doctor ever said that you have a heart condition and you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in physical activity?
Are you pregnant now or have you given birth within the last six months?
Have you had any recent surgeries?
Is your doctor currently prescribing any medication for your blood pressure or a heart condition?
Do you know of any reason why you should not engage in physical activity?

Thanks for submitting!

bottom of page