Physical Activity Readiness-Follow up Questionnaire-BlossomWholeWellness

Physical Activity Readiness-Follow up Questionnaire

Please complete these follow-up questions about medical conditions identified in the previous questionnaire. If you answer yes to a question, please complete the sub-questions (#a, #b, #c, etc). If you answer NO, you may continue to the next numbered question.

1. Do you have Arthritis, Osteoporosis, or Back Problems? (If NO, go to question 2)

Yes

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

1b. Do you have joint problems causing pain, a recent fracture caused by osteoporosis or cancer, displaced vertebra, and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Yes

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

Yes

2. Do you currently have cancer of any kind? (If NO, go to question 3)

Yes

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma, head, and/or neck?

Yes

2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?

Yes

3. Do you have a heart or cardiovascular condition? (This includes coronary artery disease, heart failure, diagnosed abnormality of heart rhythm)

Yes

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or treatments)

Yes

3b. Do you have irregular heart beat that requires medical management?

Yes

3c. Do you have chronic heart failure?

Yes

4. Do you currently have high blood pressure?

Yes

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if. you are not currently taking medications or other treatments)

Yes

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?

Yes

5. Do you have any metabolic conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes

Yes

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?

Yes

5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? (Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, etc)

Yes

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

Yes

5d. Do you have any other metabolic conditions (such as pregnancy-related diabetes, chronic kidney disease, or liver problems)?

Yes

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

Yes

6. Do you have any mental health conditions or learning difficulties? (This includes Alzheimer's, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome)

Yes

6a. Do you have difficulty controlling your condition with medications or physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

Yes

7. Do you have a respiratory disease? (This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure)

Yes

7a. Do you have difficulty controlling your condition with medications or physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

Yes

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

Yes

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

Yes

8. Do you have a spinal cord injury? (This includes Tetraplegia and Paraplegia)

Yes

8a. Do you have difficulty controlling your condition with medications or physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

Yes

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

Yes

9. Have you had a stroke? (This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event)

Yes

9a. Do you have difficulty controlling your condition with medications or physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

9b. Do you have any impairment in walking or mobility?

Yes

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

Yes

10. Do you have any other medical conditions not listed above or do you have two or more medical conditions?

Yes

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

Yes

10b. Do you have a medical condition not listed (such as epilepsy, neurological conditions, kidney problems)?

Yes

10c. Do you currently live with two or more medical conditions?

Yes

10d. Please list any other medical condition(s) and any related mediation(s) here:

If you answered NO to all of the FOLLOW-UP Questions about your medical condition, you are ready to become more physically active - sign the PARTICIPANT DECLARATION below:

It is advised you consult a qualified exercise professioanl to help you develop a safe and effective physical activity plan to meet your health needs.
You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.
As you progress you should aim to accumulate 150 minutes or more of moderate intensity physical activity per week.
If you are over the age of 45 years and NOT accustomed to regular vigorous to maximal effort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.

If you answered YES to one or more of the following questions about your medical condition, you should seek further informatoin before becoming more physically active or engaging in a fitness appraisal.

Delay becoming more active if:

You have a temporary illness such as a cold or fever; it is best. towait until you feel better.
You are pregnant - talk to your health care practitioner, your physician, or a qualified exercise professional.
Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.

PARTICIPANT DECLARATION:

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 center may retain a copy of this form for records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

**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.

First Name

Last Name

Phone Number

Your Signature

Date

Parent/Guardian/Care Provider Signature

Date