One to one

Name

Age

Address

Telephone

Email

Emergency Telephone

1. Has your Doctor ever said that you have a heart condition and that you should only do physical activity recommended by a Doctor? 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 physical activity? 2. Do you feel pain in your chest when you do physical activity? Yes No

3. In the past month, have you had chest pain when you were not doing physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? Yes No

4. Do you lose your balance because of dizziness or do you ever lose consciousness? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? Yes No

5. Other than your back, do you have any other joint or bone problems that could be made worse by a change in your physical activity? 5. Other than your back, do you have any other joint or bone problems that could be made worse by a change in your physical activity? Yes No

6. Is your Doctor currently prescribing drugs (for example, water tablets) for your bloody pressure or heart condition? 6. Is your Doctor currently prescribing drugs (for example, water tablets) for your bloody pressure or heart condition? Yes No

7. Do you know of any other reason why you should not do physical activity? 7. Do you know of any other reason why you should not do physical activity? Yes No