Health Questionnaire 2019
If you are between the ages of 15 and 69, and planning to become much more physically active than you are now, this health questionnaire will tell you if you should check with your doctor before you start.

Please read the following questions carefully and answer each one honestly.

All information will be treated confidentially.
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1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
2. Do you feel pain in your chest when you do physical activity? *
3. In the past month, have you had chest pain when you were not doing physical activity? *
4. Do you lose your balance because of dizziness or do you ever lose consciousness? *
5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? *
6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart conditions? *
7. Do you know of any other reason why you should not do physical activity? *
If you answered YES to one or more questions, you should talk with your doctor BEFORE you start becoming much more physically active. If you answered NO to all questions, it is reasonably safe for you to participate in physical activity, gradually building up from your current level.
Assumption of Risk *
"I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities which may include aerobic exercise, resistance exercise and stretching. I realise that my participation in these activities involves the risk of injury."
"I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury." *
Please sign by entering your full name below.
Please note:
This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer yes to any of the questions.
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