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Physical Activity Readiness Questionnaire

Please read each question carefully and answer honestly by ticking YES/NO.

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had a chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not take part in physical activity?

If YES, please comment:

If you answered YES to any of these questions: You should consult with your doctor to clarify that it’s safe for you to become physically active at the current time.

Destination Wellness recommends that you consult your GP regarding the suitability of undertaking an exercise programme and following all the safety instructions required before beginning to exercise.  When participating in an exercise or exercise programme, there is the possibility of sustaining a physical injury. If you engage in this exercise programme, you agree that you do so at your own risk, are voluntarily participating in these activities and assume all risk of injury to yourself.  All contracts subject to and governed by English Law and the exclusive jurisdiction of the Courts of England and Wales”.

I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

Thanks for submitting!

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