RTTPT Health Check
Name
*
First Name
Last Name
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Email
*
example@example.com
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Phone Number
*
Please enter a valid phone number.
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Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?
Yes
No
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Do you ever experience unexplained pains in your chest at rest or during physical activity / exercise?
Yes
No
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Do you ever feel faint or have spells of dizziness during physical activity / exercise that causes you to lose balance?
Yes
No
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Have you had an asthma attack requiring immediate medical attention at any time in the past 12 months?
Yes
No
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If you have diabetes (type 1 or type 2) have you had trouble controlling your blood glucose in the past 3 months
Yes
No
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Do you have any diagnosed muscle, bone or joint problems that you have been told could be made worse by participating in physical activity / exercise?
Yes
No
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Do you have any other medical conditions that make it dangerous for you to participate in physical activity / exercise?
Yes
No
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Is there any reason you can think of why you shouldn’t participate in physical activity / exercise?
Yes
No
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Should be Empty: