PHYSICAL ACTIVITY QUESTIONNAIRE FOR:__________________________________________
READ CAREFULLY AND CIRCLE YES OR NO IF IT APPLIES TO YOU.
YES NO 1. HAS YOUR DOCTOR EVER TOLD YOU HAVE HEART TROUBLE?
YES NO 2. DO YOU FREQUENTLY HAVE PAINS IN YOUR HEART OR CHEST?
YES NO 3. DO YOU OFTEN FEEL FAINT OR HAVE SPELLS OF DIZZINESS?
YES NO 4. HAS A DR. EVER SAID YOUR BLOOD PRESSURE WAS TOO HIGH?
YES NO 5. HAS YOUR DR. EVER TOLD YOU THAT YOU HAVE A JOINT OR BONE PROBLEM, LIKE ARTHRITIS, THAT CAN BE AGGRAVATED BY EXERCISE?
YES NO 6. DO YOU HAVE BACK OR NECK PROBLEMS?
YES NO 7. IS THERE A GOOD PHYSICAL OR PSYCHOLOGICAL REASON NOT MENTIONED HERE WHY YOU SHOULD NOT FOLLOW AN ACTIVITY PROGRAM IF YOU WANTED TO?
YES NO 8. ARE YOU OVER AGE 65 AND NOT ACCUSTOMED TO PHYSICAL EXERCISE?
IF YOU ANSWERED:
YES TO ONE OR MORE QUESTIONS:
If you haven’t recently done so, consult with your doctor by phone or in person, before increasing
your activity level! Tell him what questions you answered yes to on survey. After medical evaluation,
seek advice from your doctor as to your suitability for: unrestricted physical activity, probably on a
gradually increasing basis; restricted or supervised activity to suit your needs, at least initially. If
your doctor is aware of the problem, put your initials and a note next to the question(s) you
answered “yes” to, explaining why it is okay to proceed with caution.
NO TO ALL QUESTIONS:
If you answered accurately, you have reasonable assurance of your present suitability for a
graduated exercise program. If you have a temporary minor illness, like a cold, postpone increased
WAIVER/RELEASE FORM YOU AGREE TO THE TERMS OF THIS RELEASE FORM. TRAINING AND EXERCISE ARE STRENUOUS ACTIVITIES. YOU, THE GUEST/CLIENT/MEMBER, ARE AWARE THAT YOU ARE ENGAGING IN PHYSICAL EXERCISE AND THAT THE USE OF EQUIPMENT, TRAINING AND INSTRUCTION, COULD CAUSE INJURY TO YOU. YOU ARE
VOLUNTARILY PARTICIPATING IN THESE ACTIVITIES AND ASSUME ALL RISKS OF
INJURY THAT MIGHT RESULT. YOU AGREE TO WAIVE ANY CLAIMS OR RIGHTS YOU
MIGHT OTHERWISE HAVE TO SUE %trainer-name%, OR ANY AGENT, EMPLOYEES OR INSTRUCTORS, OR %business-name%, FOR INJURY TO YOU AS A RESULT OF THESE ACTIVITIES. IT IS ALWAYS ADVISABLE AND RECOMMENDED TO CONSULT YOUR PHYSICIAN BEFORE UNDERTAKING THIS OR ANY EXERCISE PROGRAM.