New Jersey Sports Medicine and Performance Center

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   PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

PATIENT NAME:

MEDICATIONS:

YES  NO

1.  Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity

2.  Do you have chest pain brought on by physical activity?

3.  Have you developed chest pain within the past month?
                        
4.  Do you tend to lose consciousness or fall over as a result of dizziness?

5.  Do you have a bone or joint problem that could be aggravated by physical activity?

6.  Has a doctor ever recommended medication for your blood pressure or a heart condition?

7.  Are you aware, through you own experience or a doctor’s advice, of any other physical reason against your
exercising without medical supervision?

NAME:

SIGNATURE:

DATE:

IF YES TO ONE OR MORE QUESTIONS: Consult with your family physician concerning those questions
before increasing your physical activity or performing an exercise test.

IF NO TO ALL QUESTIONS: You can be reasonably assured that you can participate in a graduated exercise
program.  A graduated increase in proper exercise promotes good fitness development while minimizing or
eliminating discomfort.

It is recommended that you postpone fitness testing if you have a minor illness/cold.

MEDICAL RECORDS RELEASE
If you would like us to send a copy of your medical records to your personal Healthcare Provider, please
authorize as follows:
I WOULD LIKE MY MEDICAL RECORDS SENT TO THE FOLLOWING PHYSICIAN AND I HEREBY
AUTHORIZE RELEASE OF MY MEDICAL RECORDS:

Physician's Name:

Address:

City:

Zip:

State:

Phone:

Fax:

Signature / Parent or Guardian:

Date:

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