Although there are many health benefits associated with regular exercise the completion of this form is a sensible first step for you to privately take in your home. 




For most people, physical activity should not pose any problems or hazards - however, physical activity might be inappropriate for certain people. Common sense is your best guide when answering these few questions.


Please read the carefully and answer YES or NO to the questions if it applies to you. 

1. Has your doctor ever said you have heart trouble?

2. Do you frequently have pains in your heart and chest?
3. Do you often feel faint or have spells of severe dizziness?
4. Has a doctor ever said your blood pressure was too high?
5. Has your doctor ever told you that you have a bone or joint problem(s), such as arthritis that has been aggravated by exercise, or might be made worse with exercise?

6. Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to?
7. Are you or have you been pregnant in the last 6 months?

8. Do you suffer from any problems of the lower back, i.e., chronic pain, or numbness?
9. Are you currently taking any medications?

10. Do you currently have a disability or a communicable disease?

If you answered NO to all questions above, it gives a general indication that you may participate in physical and aerobic fitness activities. The fact that you answered NO to the above questions is no guarantee that you will have a normal response to exercise. If you answered Yes to any of the above questions, then you may need written permission from a physician before participating in physical and aerobic fitness activities.

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Date of Birth:

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