Name *

First Name

Last Name

Do you currently exercise?

Yes

No

Age Range

18-30

30-40

40-50

60+

Do you smoke?

Yes

No

Do you drink?

Yes

No

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?

Yes

No

Do you feel pain in your chest when you perform physical activity?

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity?

Yes

No

Do you lose your 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?

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?

Yes

No

Do you know of any other reason why you should not engage in physical activity?

Yes

No