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Readiness for Physical Activity Questionnaire.docx
Physical Activity Questionnaire

Name: .................................................................................................
Tel:……………………………………………………………….
Email:……………………………………………………………

This must be completed by all clients
This questionnaire is only for those aged between 15 and 69

Regular activity is fun and healthy, and increasingly more people are starting to become more active. Being more active is very safe for most individuals; however, some individuals may need to check with their doctor before embarking on a programme of physical activity.
If you are planning on becoming much more physically active than you are currently you will need to answer the questions below. If you are aged over 69 years of age you must check with your doctor before embarking on increased physical exercise.
Please read the questions below and answer each one honestly checking Yes or No.

| 1. 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 |



| 2. Do you feel pain in your chest when you do physical activity? | Yes | No |

 


| 3. In the past month, have you had chest pain when you were not doing physical activity? | Yes | No |

 


| 4. Do you lose your balance because of dizziness or do you ever lose consciousness? | Yes | No |

 


| 5.Do you have a bone or joint problem (e.g. back, knee or hip) that could be made worse by a change in your physical activity | Yes | No |

 


| 6. Are you currently taking prescribed drugs from your doctor.(e.g. for blood pressure or water retention, heart condition or indeed any other medical condition | Yes | No |

 


| 7. Do you know of any other reason why you cannot or should not participate in physical activity. | Yes | No |

 

 

If you answered YES, to one or more questions:
Talk to your GP by phone or in person BEFORE you start to become more physically active or BEFORE you have a fitness appraisal. Tell your doctor which questions you have answered YES to.

- You may be able to do any activity you wish as long as you start slowly and build up gradually. You may need to restrict your activities to those that are safe for you. Discuss with your doctor the activities that you wish to participate in and follow his/her advice.

If you answered No to all the questions:
If you were 100% honest in ALL of your NO answers then, you can be reasonably sure that you can:

- Start to become more physically active- begin slowly and build up gradually. This is the safest and easiest way to go.
- Ensure that you have a physical appraisal- this is an excellent way to establish your basic fitness so that you can plan the best way to live a much more active life and become fitter. It is highly recommended that you have your blood pressure evaluated.

If your reading is excess of 144/94 you should discuss with your GP before increasing your activity.

When to delay becoming more active

- If you are not feeling well due to temporary illness such as a cold or fever –wait until you feel better or
- If you are or may be pregnant- you must discuss becoming more active with your GP.

PLEASE NOTE
If your general health deteriorates after you have completed the questionnaire so that a Yes would become a No you must inform your instructor who will assess if your plan should be changed.
Note if this questionnaire must be completed before training can commence – This document may be used for legal and administrative purposes.
“I have read, understood and completed this questionnaire. All questions answered are correct at time of signing this document. Any changes to my general health will be notified to may trainer at the earliest opportunity”
Print Name


Signature Date


Signature of Parent or Guardian (for participants under 18 years of age)

 

Note: this document is valid for 12 months from date of signature but becomes invalid if your health deteriorates so that you would have to answer yes to one of the above questions

 

 

 

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