Birthday*

Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?*

Do you have high blood pressure?*

Do you have Diabetes Mellitus or any other metabolic disease?*

Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)?*

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

Have you ever felt pain in your chest when you do physical exercise?*

Is your doctor currently prescribing you drugs or medication?*

Have you ever suffered from unusual shortness of breath at rest or with mild exertion?*

Is there any history of Coronary Heart Disease in your family?*

Do you often feel faint, have spells of severe dizziness or have lost consciousness? *

Do you currently drink more than the average amount of alcohol per week (21 units for men and 14 units for women)?*

Do you currently smoke?*

Do you currently exercise less than 3 times a week?*

Are you, or is there any possibility that you might be pregnant?*

Do you know of any other reason why you should not participate in a program of physical activity?*

Date