Physical Activity Readiness Questionnaire

Personal Details

Please provide your contact information

First Name *

Last Name *

Email *

Phone Number *

Address *

Date of Birth *

Emergency Contact Details *

Physical Activity Readiness

Please answer the following health screening questions

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

Yes

No

Do you ever feel pain in your chest when you do physical activity? *

Yes

No

Have you ever had chest pain when you were not doing physical activity? *

Yes

No

Do you lose your balance because of dizziness or do you ever lose consciousness/feel faint? *

Yes

No

Are you currently taking any medication that I need to be aware of? *

Yes

No

Do you have a joint or back problem which could be made worse by exercise? *

Yes

No

Are you pregnant or have you had a baby in the last 6 months? *

Yes

No

Do you know of any other reason why you should not participate in physical activity? *

Yes

No

Please add any explanations here

If you have answered yes to any of the above questions and are concerned about doing exercise, please speak to your GP before starting an exercise programme.

Lifestyle Questionnaire

Help us understand your current lifestyle

Age *

Do you smoke? *

Yes

No

How often do you drink alcohol? *

Please describe your current weekly food habits *

Please describe your current weekly exercise habits *

Are you employed? If so, what as? *

Please describe your living arrangements *

What are you wanting to achieve through training with Move Me Happy? *

Do you envisage any obstacles with this?

Is there any other information that you feel is relevant?

Declaration

Please confirm that you have read and understood this questionnaire

I have read, understood and completed this questionnaire to the best of my knowledge.

Signature (type your name) *

Date *

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