Name *

First Name

Last Name

Childs Name (Where Applicable)

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Participant Date Of Birth *

MM

DD

YYYY

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

YES

NO

Do you feel pain in your chest when you do physical activity? *

YES

NO

In the past month, have you had chest pain when you were not doing physical activity? *

YES

NO

Do you lose your balance because of dizziness or do you ever lose consciousness? *

YES

NO

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

YES

NO

Is your doctor currently prescribing drugs for blood pressure or heart condition? *

YES

NO

Do you know of any other reason why you should not do physical activity? *

YES

NO