1. Have you ever been advised by your doctor that you have a heart condition and should only do physical activity recommended by a doctor? *

No

Yes

2. Do you ever feel pain in your chest when you do physical activity? *

No

Yes

3. Have you ever had any chest pain when you were NOT doing physical activity?

No

Yes

4. Do you ever feel faint or have spells of dizziness?

No

Yes

5. Have you ever had either high or low blood pressure?

No

Yes

6. Have you ever had asthma, chronic bronchitis or any other chest ailments?

No

Yes

7. Do you suffer from back pain or any orthopaedic problem/condition?

No

Yes

8. Do you suffer from severe headaches or migraines?

No

Yes

9. Are you currently taking any medication?

No

Yes

10. Are you recuperating from a recent illness/operation/injury:

No

Yes

11. Are you pregnant or have had a baby in the last 6 months?

No

Yes

12. Have you any medical condition that we should be aware of?

No

Yes

13. Is there any other reason why you should not participate in physical activity?

No

Yes

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I have read, understood and completed this questionnaire

All questions have been answered to the best of my knowledge.

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