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Physical Activity Readiness Questionnaire

Personal Details

Emergency Contact

Health Conditions

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
Yes
No
Do you have a bone or joint problem (for instance, back, knee or hip) that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Yes
No
Have you been diagnosed with a neurological condition?
Yes
No
Do you know of any other reason you should not do physical activity?
Yes
No

If you answered YES to one or more of the above questions:

You should consult with your doctor to clarify that it is save for you to become physically active at this current time and in your current state of health.

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the health condition questions. It is your responsibility to inform us of any changes to your medical condition.

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