Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

1. Do you have a cholesterol count higher than 200? *

YES

NO

Don't Know

2. Did you ever, or do you presently, have a heart murmur? *

YES

NO

Don't Know

3. Do you have angina pectoris (spams of pain in the middle of your chest)? *

YES

NO

Don't Know

4. While performing any kind of exercise or work, have you experienced pain or pressure or a squeezing sensation in your chest? *

YES

NO

Don't Know

5. Have you ever had bouts of rapid heart rate, irregular heart rate or palpitations? *

YES

NO

Don't Know

6. Have you ever taken any medications for your heart? *

YES

NO

Don't Know

7. Do you have diabetes? *

YES

NO

Don't Know

8. Has a physician ever told you that you have high blood pressure or hypertension? *

YES

NO

Don't Know

9. Are you overweight by over 20 pounds? *

YES

NO

Don't Know

10. Do you smoke more than a pack of cigarettes a day? *

YES

NO

Don't Know

11. Has a blood relative had a heart attack or heart trouble before the age of 60? *

YES

NO

Don't Know

12. Do you have any chronic illnesses? *

YES

NO

Don't Know

13. Do you have any respiratory problems? *

YES

NO

Don't Know

14. Do you have any problem that limits motion in your muscles, joints, or any other part of your body? *

YES

NO

Don't Know

15. Do you find yourself short of breath in any activity which doesn't usually affect other people that way? *

YES

NO

Don't Know

16. Do you have any lower back problems? *

YES

NO

Don't Know

17. Are there any other physical conditions that possibly could limit or Impact your participation in this class? *

YES

NO

Don't Know

I confirm that all the information I provided in this readiness form is true accurate.

I confirm