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Please mark YES or No to the following: YES NO Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity? ____ ____ Do you frequently have pains in your chest when you perform physical activity? ____ ____ Have you had chest pain when you were not doing physical activity? ____ ____ Do you lose your balance due to dizziness or do you ever lose consciousness? ____ ____ Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? ____ ____ Are you pregnant now or have you given birth within the last 6 months? ____ ____ Have you had a recent surgery? ____ ____ If you have marked YES to any of the above, please elaborate below: _____________________________________________________________________________ _____________________________________________________________________________ Do you have any chronic illness or physical limitations such as Asthma, diabetes? Yes/No _____________________________________________________________________________ Do you...

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