Physical activity screening questionnaire

    Do you currently participate in any form of exercise?
    YesNo

    Can you jog for 20 minutes without fatigue?
    YesNo

    Can you brisk walk for 30 minutes without fatigue?
    YesNo

    Lifestyle questionnaire

    Do you work at the desk each day?
    YesNo

    Diet questionnaire

    Describe your typical day:

    Goals

    Par-Q

    Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
    YesNo

    Do you feel pain your chest when you do physical activity?
    YesNo

    In the past month, have you had chest pain when you were not doing physical activity?
    YesNo

    Do you lose your balance because of dizziness or do you ever lose consciousness?
    YesNo

    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?
    YesNo

    Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
    YesNo

    Do you know of any other reason why you should not do physical activity?
    YesNo

    Personal information






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