1. Has a doctor said that you have a heart condition and recommended only medically supervised activity?

Yes/No

2. Do you have chest pain brought on by physical activity?

Yes/No

3. Have you developed chest pain in the past month?

Yes/No

4. Do you tend to lose consciousness or fall over as a result of dizziness?

Yes/No

5. Do you have a bone or joint that could be aggravated by the proposed physical activity?

Yes/No

6. Has a doctor ever recommended medication for your blood pressure or a heart condition?

Yes/No

7. Do you have any diagnosed form of diabetes?

Yes/No

8. Are you aware through your own experience, or a doctor's advice, of any other physical reason against your exercising without medical supervision?

Yes/No
 

NOTE: If you have a temporary illness, such as a common cold, or are not feeling well at this time, postpone activity.