Physical Activity Readiness Questionnaire First Name:
Surname:
Emergency Contact details: Name: Number: Please answer all questions honestly. All information is kept confidential. Medical Questionnaire 1.
Yes
Have you ever had a stroke?
When: 2.
Treatment:
Have you ever had heart surgery?
When: 3.
Treatment:
Treatment:
Type II
Treatment/Medication:
Do you have high blood pressure?
When Diagnosed: 6.
Treatment/ Medication:
Do you have angina or suffer from chest pains?
GTN Spray/tablet: Yes 7.
Rehab:
Do you have diabetes?
Type I 5.
Rehab:
Have you ever had a heart attack?
When: 4.
Rehab:
No
Frequency of use:
Do you have any respiratory condition?
Condition:
Treatment/ Medication:
8.
Do you have any mental health issues like anxiety/depression?
9.
Do you have epilepsy?
Medication: 10. Do you have arthritis or osteoporosis? Type:
Medication:
11. Are you currently taking any other medication? Details: 12. Do you smoke? Ex-smoker?
Limitations:
No