If you are planning to take part in physical activity or an exercise class, start by answering the questions below. If you are between the ages of 15 and 69 the questionnaire will tell you if you should consult with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

1) Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
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2) Do you ever feel pain in your chest when you do physical activity?
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3) Have you every had chest pain when you were not doing physical activity?
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4) Do you ever feel faint or have spells of dizziness?
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5) Have you ever been told that you have high blood pressure?
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6) Are you currently taking any medication of which the instructors should be made aware?
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7) Do you have a joint problem that could be made worse by exercise?
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If "yes" what?

INFORMATION WILL BE TREATED CONFIDENTIALLY:

8) Are you pregnant or have you had a baby in the last six months?
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9) Is there any other reason why you should not participate in physical activity?
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If "yes" what?

If you have answered "Yes" to one or more questions:

Talk to your doctor by phone or in person before you start becoming more physically active and before you have a fitness assessment. Tell your doctor about the questionnaire and which questions(s) you answered "yes" to. You may be able to do any activity you want – as long as you begin slowly and build up gradually, or you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kind of activity you wish to participate in and follow his/her advice.

If you have answered "No" to all questions:

You can be reasonably sure that you can start to become more physically active and take part in a suitable exercise programme. Remember – begin slowly and build up gradually. Please Note: If your health changes so that subsequently you answer "yes" to any of the above questions, inform your fitness or health professional immediately. Ask whether you should change your physical activity or exercise plan. Delay becoming more active if you feel unwell because of temporary illness such as cold or flu – wait until you are better.

I have read, understood and completed this questionnaire

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All questions have been answered to the best of my knowledge

Y

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