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Physical Activity Readiness Questionnaire

Please fill out the following form. Information will only be used by 50Grand H&F Personnel.

First name

Last name

Email

Height

Phone

Date of Birth

Weight

Gender

Have you been told by a medical professional to abstain from physically strenuous activity?

Yes

No

If you answered "yes" to previous question, have you since been cleared to engage in routine physical exercise?

Have you been diagnosed or had any problems with any of the following: (Check all that apply)

Heart Problems

Hypertension (High BP)

Diabetes

Asthma

Kidney Disease

Liver Disease

Cancer (of any kind)

HIV/AIDS

Knee or Back Injuries

Other (please explain in box below)

If you chose "Other" in the question above, please explain here:

Have you been hospitalized in the last 12 months? *

No

Yes

Are you suffering from a medical condition, illness, or injury? *

No

Yes

If you answered yes to any of the above 2 questions, please elaborate:

How would you describe your daily level of activity?

Have you ever had an exercise program that you followed regularly?

Please tell us what your fitness goals are: Be specific (i.e. I want to lose 20 lbs. over the next 3 months, etc.)

On a Scale of 1-10, how serious are you about getting into the best shape of your life?

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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