Physical Activity Readiness Questionnaire

* Denotes required fields

    Preliminary Information

    Medical History

    If answering yes to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

    Has your doctor ever said that you have a heart condition and that you should only do exercise recommended by your doctor?

    In the past month, have you had chest pain when you are not doing physical activity?

    Do you have a bone or joint problem that could be made worse by a change in your physical activity?

    Are you diabetic?

    Are you taking any medication?

    Do you feel pain in your chest when you do physical activity?

    Do you lose your balance because of dizziness or do you ever lose consciousness?

    Is your doctor currently prescribing drugs for your blood pressure or heart condition?

    Do you have a chronic cough or a condition that affects your breathing (hayfever, asthma?)

    Do you know of any other reason why you should not do physical activity?

    This physical activity clearance is valid for 12 months from the date that it is completed and becomes invalid if your condition changes so that you would answer YES to any of the medical questions.

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