Physical Activity Readiness Questionnaire-BlossomWholeWellness

Physical Activity Readiness Questionnaire

The health benefits of regular physical activity are clear; more people should engage in physical activity every day of the week. Participating in physical activity is safe for MOST people. This questionnaire will tell you whether it is necessary for you to seek further advice form your doctor OR a qualified exercise professional before becoming more physically active.

1. Has your doctor ever said you have a heart condition?

Yes

2. Has your doctor every said you have high blood pressure?

Yes

3. Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?

Yes

4. Have you every been diagnosed with another chronic medical condition (If yes please list below)?

Yes

4b. Please list condition(s) here:

5. Do you lose balance because of dizziness or have you lost consciousness in the last 12 months? (Please answer NO if your dizziness was associated with over-breathing including during vigorous exercise.)

Yes

6. Are you currently taking prescribed medicine for a chronic medical condition? (If yes, list details below)

Yes

6b. Please list condition(s) & medications here:

7. Do you currently have (or have you had within the past 12 months) a bone, join, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active?

Yes

7b. Please list conditions here:

8. Has your doctor ever said that you should only do medically supervised physical activity?

Yes

If you answered NO to all of the questions above, you are cleared for physical activity. Please sign the Participant Declaration below. If you answered YES to one or more questions above, please complete the follow-up questionnaire linked here.

PARTICIPANT DECLARATION:

If you are less than the legal age required for consent or require the assent of a care provider, your parent, guardian, or care provider must also sign this form.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that the community/fitness cetner may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable laws.

First Name

Last Name

Phone Number

Your Signature

Date

Parent/Guardian/Care Provider Signature if applicable:

Date