(Physical Activity Readiness Questionnaire)

Please fill out the following form prior to your initial assessment.

(If you answer YES to one or more of the below questions, consult your physician before engaging in physical activity.) Tell your physician which questions you answered yes to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?*
Do you feel pain in your chest when you perform physical activity?*
In the past month, have you had chest pain when you were not performing any physical activity?*
Do you lose your balance because of dizziness or do you ever lose consciousness?*
Do you have a bone or joint problem that could be made worse by a change in your physical activity?*
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?*
Do you know of any other reason why you should not engage in physical activity?*
Does your occupation require extended periods of sitting?*
Does your occupation require repetitive movements? If so, please explain.*
Does your occupation require you to wear shoes with a heel(dress shoes)?*
Does your occupation cause you mental stress?*
This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.

Thank you! Your message was sent successfully.