Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

No

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?

Yes

No

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?

Yes

No

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?

Yes

No

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?

Yes

No

Do you have any other conditions that may require special consideration for you to exercise?

Yes

No