ba689289-9989-4ff4-975a-c8b227979777
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Personal Information
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206973e9-15e2-4ed1-b24e-6413a9523e30
Textbox
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6a872ce8-65f2-482f-a61e-a0e29448a97d
Textbox
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Your Name:
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*
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9f68b777-6e4a-43ec-b5f4-e47ad6e03a42
Textbox
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Property Address:
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*
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bc9e71bc-10b6-4e21-ae30-530dfdff5eee
Textbox
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Email Address:
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*
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3c1a6fa1-b020-4a2d-a299-47a35badb106
Textbox
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Cell Phone:
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*
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33543d80-ca2c-4978-ba49-9945cfbc44a7
Textbox
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Home Phone:
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fd55f767-da80-4866-ad3c-86373c8f63fe
Textbox
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Birth Date:
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*
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fb18053a-c0ea-4f49-8181-77c9ebac7ccb
Dropdown List
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Age:
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*
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7139841f-b019-4fc3-aba8-190b70c3982b
Dropdown List
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Gender:
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*
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bf02af63-d8e6-4005-9ffb-b1f5e5b45204
Textbox
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Relationship to Property Owner:
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*
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c4c2c56f-f0e6-4f57-8a21-dc99c313222d
Dropdown List
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Own (Primary residence):
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*
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e1210295-057c-4ded-80bc-6f74755e08be
Dropdown List
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Own (Secondary home, to be used as rental)
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*
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9f1979c5-a9c8-4018-9869-4f1c6b643ece
Dropdown List
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Lease/Rent
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*
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219483f4-8cde-4a32-80f4-2c5ddf49c2d5
Textbox
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If yes, month/year lease ends:
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c5a9a4a7-509f-403c-b9a7-c653e9d4a2fe
Textbox
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Emergency Contact Name:
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*
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8d5fa983-e1af-4eac-823e-55e0012a76c9
Textbox
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Emergency Contact Phone:
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*
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3be54815-643e-44a8-8bd4-02430541ffd1
Label
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Questionnaire
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2a010cd9-a2ec-47cf-83f8-91f2c9964d13
Inline Text
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Common sense is your best guide in answering these few questions. Please read them carefully and check the correct answer opposite the question if it applies to you.
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3a93b0a7-a549-4647-95e2-25184f28c77d
Dropdown List
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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
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*
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2a0ac666-cad0-45de-880f-b6eb90dd2408
Dropdown List
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Do you feel pain in your chest when you do physical activity?
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*
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c9e523eb-c7df-4771-88b7-e1b13854ce0d
Dropdown List
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In the past month, have you had chest pain when you were not doing physical activity?
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*
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4e163a50-8342-46ee-b636-cbf8a3d7034d
Dropdown List
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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*
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565d0bb7-8912-457e-bfaa-4700713c0c16
Dropdown List
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Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
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*
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1821443c-e18b-4b76-ab2c-f2a45c230807
Dropdown List
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Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
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*
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d6e8fd32-811c-4048-828b-0d35782b2b54
Dropdown List
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Do you know of any other reason why you should not do physical activity?
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*
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87ec8508-502d-44da-be7d-682db368fd1a
Inline Text
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If you answered yes to one or more of these questions, we strongly recommend that you see your doctor before you start becoming much more physically active or before you have a fitness assessment.
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a7c3b4e9-1d73-4c34-8386-aba5b3fa37ad
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Acknowledgements
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95698dc1-ba1e-45d8-8cc8-d60b93ae4451
External Link
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Click here to download and read the: Access Card Use and Acknowledgement of Risk
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8d509712-6643-42f9-ba9a-bc872dbb3318
Electronic Signature
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7f495fcc-5f98-43cb-9625-7f965f63e4b7
Textbox
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Initials
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*
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