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Full Name*

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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

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

Yes

No

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

Yes

No

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

Yes

No

Do you have a bone or joint problem that could be made worse by a change in your physical activity?*

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*

Yes

No

How often can you commit to the gym per week?

What are your fitness goals?

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