Physical Activity Readiness Questionnaire for Attitude Wellbeing

Physical Activity Readiness Questionnaire

Please be as accurate as you can as some conditions impact what exercises you can do.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

TownCounty

PostcodeCountry
Email*
example@example.com
Mobile Number*
Date of Birth*

DayMonthYear
Health Questions
Do you have a bone/joint problem, such as arthritis, slipped disc, that might be, aggravated by exercise?*

YesNo
Is your blood pressure either high or low?*

Yes - HighYes - LowNeither
Do you have Diabetes or any other metabolic disease e.g. Hyperthyroidism?*

YesNo
Do you have raised cholesterol?*

YesNo
Do you have a heart condition?*

YesNo
Have you ever been advised not to do physical activity?*

YesNo
Have you ever felt pain in your chest when you do physical exercise?*

YesNo
Have you ever suffered from shortness of breath at rest or with mild exertion?*

YesNo
Do you frequently feel faint, or have spells of dizziness or lost consciousness?*

YesNo
Do you suffer from Epilepsy?*

YesNo
Are you, or is there any possibility that you might be, pregnant?*

YesNo
Do you know of any other reason why you should not take part in physical activity?*

YesNo
Is there any other medical information that you feel you should provide?
If you answered YES to any of the questions above, have you sought medical advice and your GP has agreed that you may exercise.*

YesNoAnswered No to all above questions
How did you find out about Attitude Wellbeing?
Signature*

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Todays date*

DayMonthYear
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Physical Activity Readiness Questionnaire

Health Questions