The Greatest Thriver: Home

1.	Yes	No	Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2.	Yes	No	Do you feel pain in your chest when you do physical activity?
3.	Yes	No	In the past month, have you had chest pain when you did any physical activity?
4.	Yes	No	Do you lose your balance becasue of dizziness or do you ever lose consciousness?
5.	Yes	No	Do you have a bone or joint problem?
6.	Yes	No	Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7.	Yes	No	Have you been told by your doctor that you have high cholesterol?
8.	Yes	No	Do you have diabetes?
9.	Yes	No	Do you have chronic fatigue, loss or strength or are deconditioned?
10.	Yes	No	Are you 20% or more above desirable body weight?
11.	Yes	No	Has stress or depression had some effect on your health in the past six months?
12.	Yes	No	Do you have glaucoma, hemorrhoids or a hernia?
13.	Yes	No	Do you know of any other reason why you should not do physical activity?
14.	Yes	No	Do you have history of asthma?
15.	Yes	No	Are you pregnant or planning on getting pregnant in the year?

How many times per week do you excercise 20 minutes or more?
Height
Weight
Date of Birth
Doctor
Doctor's Phone Number

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