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Pre-Activity Medical Questionnaire

Check that clients can safely exercise or join a physical activity. It asks about blood pressure, heart health, cholesterol, diabetes, injuries, medications, sleep and pregnancy, with room for details.

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Full Name

First Name

Last Name

Email Address

Contact Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Date of Birth

Has a doctor told you your blood pressure is too high or too low?

Yes No

Please provide details

Do you have known heart problems (abnormal ECG, prior heart attack, etc.)?

Yes No

Please provide details

Has a doctor told you your cholesterol is too high?

Yes No

Please provide details

Have you or a family member been diagnosed with diabetes?

Yes No

Please provide details

Do you have any injuries or orthopedic problems (back, knees, etc.)?

Yes No

Please provide details

Do you have stiff or swollen joints?

Yes No

Please provide details

Do you have tension or soreness anywhere in your body?

Yes No

Please provide details

Are you taking prescribed medications or dietary supplements?

Yes No

Please provide details

Do you ever have trouble sleeping?

Yes No

Are you pregnant or less than 6 weeks postpartum?

Yes No Not applicable

Has a doctor advised you not to do any type of exercise or activity?

Yes No

Please provide details

Is there any other condition or injury we should know about?

Yes No

Please provide details

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