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If you are between the ages of 15 and 69, this questionnaire will tell you if you should check with your doctor before you significantly change you physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor.

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* 1. Name

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* 2. Year of birth

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* 3. Email address

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* 4. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

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* 5. Do you feel pain in your chest when you do physical activity?

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* 6. In the past month, have you had a chest pain when you were not doing physical activity?

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

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* 8. Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?

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* 9. Is your doctor currently prescribing medication for your blood pressure or heart condition?

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* 10. Do you know of any other reason why you should not take part in physical activity?

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* 11. I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Please provide your full name to act as a signature:

0 of 11 answered
 

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