Health Questionnaire

Health Screening Questionnaire

Regular physical activity has many health benefits;  however, some people should check with their doctor before they start. If you are planning to undertake more physical activity than you are used to at present, start by answering the questions below. If you are in doubt you should check with your doctor before you start.

Please understand you are using this equipment at your own risk.

Read  the questions carefully and answer them honestly by ticking YES or NO. If you have answered YES  to any of these questions please talk to your doctor before starting to use this equipment.

  1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a  doctor?  YES/NO
  2. Do you feel pain in your chest when you do any physical activity?  YES/NO
  3. In the past month, have you had chest pain when you were not doing physical activity?  YES/NO
  4. Do you lose balance because of dizziness or do you ever lose consciousness? YES/NO
  5. Do you have a bone or joint problem that could be made worse by a change in your physical activity level?  YES/NO
  6. Is your doctor currently prescribing any medication for your blood pressure or a heart condition?  YES/NO
  7. Do you know of any other reason why you should not do physical activity.  YES/NO

If you have answered YES to any of these questions talk to your doctor BEFORE you start to exercise.

If you have answered NO honestly to all questions you can start to become more physically active. The safest way is to start slowly and build up gradually.

I have understood and answered all of the above questions honestly. I understand that I use the equipment at my own risk.

Signature:                                                                        Date: