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Medical questionnaire

Please Complete This Form

Name(Required)
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active everyday. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming more physically active.

If you are planning to become more physically active than you are now, start by answering the questions in the box below.

Please read the question carefully and answer each one honestly by ticking YES or NO.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(Required)
Do you feel pain in your chest when you do physical activity?(Required)
In the past month, have you had chest pain when you were not doing physical activity?(Required)
Do you lose your balance because of dizziness or do you ever lose consciousness?(Required)
Do you have a bone or joint problem that could be made worse by a change in your physical activity?(Required)
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?(Required)
Do you know of any other reason why you should not do physical activity?(Required)
Please note: If your health changes so that you then answer YES to any of the above questions, tell your fitness professional at The PT Factory
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Holland Street, Denton, Tameside, Manchester, M34 3WF, UK

 
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