Name *

First Name

Last Name

Name *

First Name

Last Name

Telephone

(###)

###

####

A) A diagnosis of/treatment for heart disease or stroke, or pain/discomfort/pressure in your chest during activities of daily living or during physical activity? *

Yes

No

B) A diagnosis of/treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher? *

Yes

No

C) Dizziness or lightheadedness during physical activity? *

Yes

No

D) Shortness of breath at rest? *

Yes

No

E) Loss of consciousness/fainting for any reason? *

Yes

No

F) Concussion? *

Yes

No

2. Do you currently have pain or swelling in any part of your body (such as from an injury, acute flare-up of arthritis, or back pain) that affects your ability to be physically active? *

Yes

No

3. Has a health care provider told you that you should avoid or modify certain types of physical activity? *

Yes

No

4. Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis, asthma, spinal cord injury) that may affect your ability to be physically active? *

Yes

No

I have consulted a health care provider or Qualified Exercise Professional (QEP) who has recommended that I become more physically active.

I am comfortable with becoming more physically active on my own without consulting a health care provider or QEP.

Name *

First Name

Last Name

Telephone

(###)

###

####

I have completed the health form above (modified GAQ 2018) and I confirm that the answers I have given are correct (check box if applicable).

Date

MM

DD

YYYY