Physical Activity Readiness Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
1. Has your doctor ever said you have a heart condition or high blood pressure?
*
Yes
No
1a. Do you have an irregular heartbeat that requires medical management (e.g. atrial fibrillation, premature ventricular contraction) ?
Yes
No
1b. Do you have difficulty controlling your condition with medication or other physician-prescribed therapies?
Yes
No
1c. Do you have a resting blood pressure greater than 160/90 with or without medication?
Yes
No
1d. What was your last measured blood pressure?
2. Do you feel pain in your chest at rest, during your daily living, OR during physical activity?
*
Yes
No
2a. If yes, do you have difficulty controlling your condition with medication or other physician-prescribed therapies?
Yes
No
3. Do you lose balance because of dizziness OR have you lost consciousness within the last 12 months?
*
Yes
No
4. Have you ever been diagnosed with another chronic health condition (not heart disease or high blood pressure)?
*
Yes
No
4a. Please list condition(s) here:
5. Are you currently taking any prescribed medications for a chronic health condition?
*
Yes
No
5a. Please list medication(s) here:
6. Do you currently have (or have had in the last 12 months) a bone, joint, or soft-tissue injury that could be made worse by physical activity?
*
Yes
No
7. Has your doctor ever said you should only do medically-supervised physical activity?
*
Yes
No
8. Do you have arthritis, osteoporosis, or back problems?
*
Yes
No
8a. If yes, do you have difficulty controlling your condition with medication or other physician-prescribed therapies?
Yes
No
9. Do you currently have cancer of any kind?
*
Yes
No
9a. Does your cancer involve the lungs, head, or neck?
Yes
No
9b. Are you currently receiving chemotherapy or radiation treatment?
Yes
No
10. Do you have any metabolic conditions such as Type I or Type II diabetes?
*
Yes
No
10a. Do you have trouble controlling your blood sugar levels with food, medication, or other therapies?
Yes
No
10b. Do you often suffer symptoms of low blood sugar after exercise?
Yes
No
11. Do you have any mental health problems or learning difficulties? This includes dementia, depression, anxiety, intellectual disability, down syndrome.
*
Yes
No
11a. Do you have difficulty controlling your condition with medication or other therapies?
Yes
No
12. Do you have a respiratory disease? This includes COPD and asthma.
*
Yes
No
12a. Do you have difficulty controlling your condition with medication or other therapies?
Yes
No
12b. Has your doctor ever said your blood oxygen level is low at rest or during exercise?
Yes
No
12c. Do you require supplemental oxygen?
Yes
No
12d. If asthmatic, have you used your rescue inhaler more than twice in the last week? Or have you had symptoms of chest tightness, wheezing, or labored breathing?
Yes
No
13. Do you have a spinal cord injury?
*
Yes
No
13a. Please list your injury:
13b. Do you have difficulty controlling your condition with medication or other therapies?
Yes
No
14. Have you ever had a stroke? This includes Transient Ischemic Attacks or a cerebrovascular event.
*
Yes
No
14a. Do you have difficulty controlling your condition with medication or other therapies?
Yes
No
14b. Do you have impairment in walking or mobility?
Yes
No
14c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?
Yes
No
15. Do you have any other medical conditions not listed?
*
Yes
No
15a. Please list any other medical conditions here.
By submitting this form, I certify that my answers are correct to the best of my knowledge and indemnify Stepp Up Fitness LLC from any errors or omissions. I understand that this form is a general guide for fitness readiness and not a substitute for professional medical clearance. I will inform my trainer immediately if there are any changes or updates to my condition.
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