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Physical Activity Readiness Questionnaire

I have read, understood and completed this questionnaire. All questions were answered to my full satisfaction.

Medical History

Smoking (within the last year) Yes 

No

High Blood Pressure (> 140/90) Yes 

No

History of Heart Disease (personal) Yes 

No

History of Heart Disease (family) Yes 

No

Diabetes (personal) Yes 

No

Diabetes (family) Yes 

No

Elevated Cholesterol (> 240 mg/dl) Yes 

No

Heart Murmur Yes 

No

Arrhythmia Yes 

No

Pain or discomfort in chest Yes 

No

 

Have you ever had difficulty breathing?

Yes

 

No
If so, please explain:

 

Have you ever experienced fainting or dizzy spells?

Yes

 

No
If so, please explain:

 

Have you been injured recently?

Yes

 

No
If so, please explain:

 

Are you currently taking any medication?

Yes

 

No
If so, please explain:

 

Is there any condition that might limit your participation in an exercise program?

Yes

 

No
If so, please explain:

 

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