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HEALTH QUESTIONNAIRE

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week.

 

Participating in physical activity is very safe for MOST people.

 

This questionnaire will tell you whether it is necessary for you to seek further advice from your doctor or a qualified exercise professional before becoming more physically active.

Please read the questions below carefully and answer each one honestly

Has your doctor ever said that you have a heart condition or high blood pressure? Required
Do you feel pain in your chest at rest, during your daily activities of living or when you do physical activity? Required
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) Required
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? Required
Are you currently taking prescribed medications for a chronic medical condition? Required
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. Required
Has your doctor ever said that you should only do medically supervised physical activity? Required

If you answered 'NO' to all of the questions above, you are cleared for physical activity.

By accepting below, I confirm that I have read and understood to my full satisfaction and have completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that Ruth Kincaid Health & Fitness may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law. Required

Thanks for submitting! I'll be in touch very soon.

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