Participate Activity Readiness Questionnaire
1. Has your doctor ever said you have a heart condition and that you should only perform
activity recommended by a doctor?
2. Do you feel pain in your chest when you do activity?
3. In the past month, have you had chest pain with activity?
4. Do you lose balance because of dizziness or do you ever lose consciousness?
5. Is your doctor currently prescribing drugs for your blood pressure or heart condition?
6. Do you have a bone or joint problem that could be made worse by a change
in physical activity?
7. Do you know of any reason why you should not do physical activity?
** If you are over 69 years of age, and you are not used to being very active, check with your doctor.
Medications
Name of Medication
AmountTaken For
1.
2.
3.
Do you have any medications that affect your heart rate?
If yes, please list.
If you are uncertain, please consult your doctor.
I have reviewed these questions and answered them to the best of my ability. I understand the materials will be reviewed and i may be asked to see my doctor before participating in Activities.
Birthdate: Age:
Signature: Date:
Witness Signature:
