Regular exercise is associated with many health benefits, yet any change of activity may increase the risk of injury.
Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life.
Please read each question carefully and answer every question honestly:
(Tick the appropriate answer)

1. Do you have a heart condition and should only do physical activity recommended by a physician?
2. When you do physical activity, do you feel pain in your chest? YES/NO
3. When you were not doing physical activity, have you had chest pain in the past month? YES/NO
4. Do you ever lose consciousness or do you lose your balance because of dizziness? YES/NO
5. Do you have a joint or bone problem that may be made worse by a change in your physical
activity? YES/NO
6. Is a physician currently prescribing medications for your blood pressure or heart condition? YES/NO
7. Are you pregnant? YES/NO
8. Do you know of any other reason you should not exercise or increase your physical activity? YES/NO

If you answered yes to any of the above questions, talk with your doctor BEFORE you become physically active. Tell your doctor of your intention to exercise and which questions you answered ‘yes’ to.
If at any stage your health changes, resulting in a ‘yes’ answer to any of the above questions, please seek guidance from a GP.
Muireann Lohan MISCP, MSc WMA