Name * First Name Last Name Date of Birth * MM DD YYYY Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? Yes No N/A Do you feel pain in your chest when you perform physical activity? Yes No N/A In the past month, have you had chest pain when you were not performing any physical activity? Yes No N/A Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No N/A Do you have a bone or joint problem that could be made worse by a change in your physical activity? Yes No N/A Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? Yes No N/A Do you know of any other reason why you should not engage in physical activity? Yes No N/A If you have answered YES to one or more of the above questions, please detail below and consult your physician before engaging in physical activity. General Questions What is your current occupation? Does your occupation require extended periods of sitting? Yes No Occasionally Does your occupation require repetitive movements? Yes No Occasionally If YES, please detail. Does your occupation require you to wear shoes with a heel (e.g., dress shoes)? Yes No Occasionally Does your occupation cause you mental stress? Yes No Occasionally Do you partake in any recreational physical activities (golf, skiing, etc.)? Yes No Occasionally If YES, please detail. Medical History Have you ever had any injuries or chronic pain? Yes No Occasionally If YES, please detail. Have you ever had any surgeries? Yes No If YES, please detail. Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes? Yes No If YES, please detail. Are you currently taking any medication? Yes No If YES, please detail. Additional Information Thank you! Information form Information form Information form
