Name
*
First Name
Last Name
Has your doctor ever said that you have a heart condition or high blood pressure?
No
Yes
Do you feel pain in your chest at rest, during your daily activities of living or when you do physical activity?
No
Yes
Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? Please answer ‘no’ if your dizziness was associated with over- breathing (including during vigorous exercise)
No
Yes
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
No
Yes
If you answered 'yes' above, please list conditions here:
Are you currently taking prescribed medications for a chronic medical condition?
No
Yes
If you answered 'yes' above, please list condition(s) and medications here:
Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer no if you had a problem in the past, but it does not limit your current ability to be physically active.
No
Yes
If you answered 'yes' above, please list condition(s) here:
Has your doctor ever said that you should only do medically supervised physical activity?
No
Yes
Participant declaration
