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HEALTH SCREENING QUESTIONNAIRE

Has your doctor ever said that you have a heart condition and that you should only do physical
activity recommended by a doctor?
Yes No
  
Do you feel pain in your chest when you do physical activity? Yes No
  
In the past month, have you had chest pain when you were not doing physical activity? Yes No
  
Do you lose balance because of dizziness or do you ever lose consciousness? Yes No
  
Do you have a bone or joint problem that could be made worse by a change in your physical activity level? Yes No
  
Have you ever had any problems with your back? Yes No
  
Is your doctor currently prescribing any medication for your blood pressure or a heart condition? Yes No
  
Is there any family history of heart disease, stroke, raised cholesterol or high blood pressure? Yes No
  
Do you suffer from diabetes/epilepsy/asthma? Yes No
  
Are you pregnant, or have you given birth in the last six weeks? Yes No
  
Do you have, or have you had any illnesses recently? Yes No
  
Have you recently had surgery? Yes No
  
Do you know of any other reason why you should not do physical activity? Yes No
  
What are your aims for exercising?
  
Present and past activity levels, how often and what type?


 






 

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