PRE ACTIVITY QUESTIONNAIRE
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Phone Number
Please tick Yes or No to these following questions. If answered yes, please provide a doctors note giving permission to join.
Has a doctor ever said that you have a heart condition and not to take part in physical activity?
Yes
No
Do you have chest pain brought on by physical activity?
Yes
No
Have you developed chest pain in the past month?
Yes
No
Do you lose consciousness or fall over as a result of dizziness?
Yes
No
Do you have a bone or joint problem that could be aggravated by physical activity?
Yes
No
Has a doctor ever recommended medication for your blood pressure or a heart condition?
Yes
No
Has a doctor advised you to only take part in physical activity with medical supervision?
Yes
No
In case of an emergency please can you provide a contact name and telephone number.
SUBMIT
Should be Empty: