Name *

First Name

Last Name

*IMPORTANT! EXERCISE PRE-PARTICIPATION HEALTH SCREENING QUESTIONAIRE: Step 1

SYMPTOMS Do you experience:

chest discomfort with exertion

unreasonable breathlessness

dizziness, fainting, blackouts

ankle swelling

unpleasant awareness of a forceful, rapid, or irregular heart rate

burning or cramping sensations in your lower legs when walking short distances

NOTE: If you DID mark any of these statements under the symptoms, STOP. You will need medical clearance before engaging in or resuming exercise. Or may need to use a facility with a medically qualified staff. ( If you DID NOT mark any symptoms, continue to steps 2 & 3).

Because I care about your safety and comfort, will you be able to obtain a doctors release before our first session? (find release form on my site)

yes

no

I don't have a primary doctor

Step 2

CURRENT ACTIVITY Have you performed planned, structured physical activity for at least 30 minutes at moderate intensity on at least 3 days per week for at least the past 3 months?

yes

no

Step 3

MEDICAL CONDITIONS have you had or currently have:

a heart attack

heart surgery, cardiac catheterization, or coronary angioplasty

pacemaker/implantable cardiac defibrillator/rythm disturbance

heart valve disease

heart failure

heart transplantation

congenital heart disease

diabetes

renal disease