Physical Readiness Questionnaire
Please read, fill out, sign and submit this form prior to your treatment.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
1 - Has your doctor ever said that you have a heart condition?
*
Yes
No
2 - If YES to 1, has he/she recommended that you only participate in specific activities?
*
Yes
No
3 - Is there a history of heart disease in your closest family (under 55)?
*
Yes
No
4 - Do you experience chest pain brought on by physical activity?
*
Yes
No
5 - Have you developed any other chest pain in the past?
*
Yes
No
6 - Do you ever lose consciousness, become dizzy, and/or lose your balance?
*
Yes
No
7 - Do you have a bone or joint problem that could be aggravated by exercise?
*
Yes
No
8 - Do you have any other injuries or medical conditions?
*
Yes
No
9 - Are you currently on any medication?
*
Yes
No
10 - Are you pregnant or have you given birth within the last ten weeks?
*
Yes
No
11 - Are you aware, through your own experience or a doctor’s advice, of any other reason you should not exercise without medical approval?
*
Yes
No
If you have answered YES to any of the above questions, please use the box below to provide details andstate the relevant question number.
*
A doctor’s note may be required prior to training if 3 or more YES answers have been given to the abovequestions.If you have a temporary illness (eg. flu, fever, feeling unwell), and/or suffer an injury,it is advised that youpostpone the proposed activity (unless for rehabilitative purposes).The information provided is confidential and will not be released or revealed without your written consent.I have read and fully understand the questions asked of me and confirm that the answers I have given arecorrect to the best of my knowledge. Should anything occur that changes the circumstances above, I willcease exercise and notify a member of the staff immediately.In signing this form, I understand that I carry full responsibility for myself in engaging in physical activity.
*
Date
-
Month
-
Day
Year
Date
Submit
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