1. Has your doctor ever said you have heart trouble?
Yes,
2. Do you frequently have pains in your heart and chest?
Yes,
3. Do you often feel fain or have spells of severe dizziness?
Yes,
4. Has a doctor ever said your blood pressure was too high?
Yes,
5. Has your doctor ever told you that you have a bone or joint problem(s),
such as arthritis that has been aggravated by exercise, or might be made
worse with exercise?
Yes,
6. Is there a good physical reason, not mentioned here, why you should not
follow an activity program even if you wanted to?
Yes,
7. Are you over age 60 and not accustomed to vigorous exercise?
Yes,
8. Do you suffer from any problems ofthe lower back, i.e., chronic pain, or
numbness?
Yes, __________^ ^
9. Are you currently taking any medications? If YES, please specify.
Yes,
10. Do you currently have a disability or a communicable disease? If YES,
Please specify,
Yes,
11. Do you currently have diabetes, thyroid, or any other diseases? If YES,
Please specify.