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HEALTH QUESTIONS

1. Do you have a bone or joint or recent injury that could have be made worse by a change in your physical activity?

YES NO

2. Have you had any form of operation in the past 6-12 month, or are due to have any surgeries?

YES NO

3. Have you recently had any chest pains when not undertaking physical activity?

YES NO

4. Do you feel pain in your chest not undertaking physical activity?

YES NO

5. Has your doctor ever said you should only carry out physical activity under medical supervision?

YES NO

6. Do you ever lose you balance because of dizziness or do you ever lose consciousness?

YES NO

7. Are you currently pregnant or have been pregnant within the past 6 months?

YES NO

8. Do you smoke?

YES NO

9. Do you suffer from Asthma?

YES NO

10. Are you diabetic?

YES NO

11. Are you currently taking any medication that you have not mentioned?

YES NO

12. Are you epileptic?

YES NO

13. Are you under any form of medical supervision or undergoing any treatment that you have not mentioned? If answer is Yes, please give details.

YES NO

14. Do you know of any reason not mentioned why you should not carry out physical activity? If answer is yes, please give details.

YES NO
Details: