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About Your Health

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

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

Yes No

In the past month, have you had chest pain when you were not doing 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 (for example, back, knee or hip) that could be made worse by a change in activity?

Yes No

Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in activity?

Yes No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart conditions?

Yes No

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

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