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Physical Activity Readiness Questionnaire
1. Date
MM
DD
YYYY
2. Name
First Name
Last Name
3. Age
4. Height
5. Weight
6. Physician's Name
7. Phone
(###)
###
####
8. Email
*
9. 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
10. Do you feel pain in your chest when you perform physical activity?
Yes
No
11. In the past month, have you had chest pain when you were not performing any physical activity?
Yes
No
12. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
13. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
14. Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Yes
No
15. Do you know of any other reason why you should not engage in physical activity?
Yes
No
If you have answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.
16. What is your current occupation?
17. Does your occupation require extended periods of sitting?
Yes
No
18. Does your occupation require extended periods of repetitive movements? (If yes, please explain.)
19. Does your occupation require you to wear shoes with a heel (dress shoes)?
Yes
No
20. Does your occupation cause you anxiety (mental stress)?
Yes
No
21. Do you partake in any recreational activities (golf, tennis, skiing, etc.)? (If yes, please explain.)
22. Do you have any hobbies (reading, gardening, working on cars, exploring the Internet, etc.)? (If yes, please explain.)
23. Have you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? (If yes, please explain.)
24. Have you ever had any surgeries? (If yes, please explain.)
25. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol or diabetes? (If yes, please explain.)
26. Are you currently taking any medication? (If yes, please list.)
Thank you!
