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PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
1. Has a doctor ever said you have a heart condition and recommended only medically supervised physical activity2. 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?
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 RELEASEIf 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:
Signature / Parent or Guardian:
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(if less than 18 years of age, responses were answered by parent/guardian whose name and signature appear above)