Module 12 For each section please check the appropriate box daly Number of ‘Confidential. For personal use only. hours sleep | Monday Tuesday | Wednesday last night “Thurseay Friday Saturday <4 How would you describe the quality of sleep you Very deep ‘experienced last night? Normat Restless Bad with breaks Ila not stoop ‘The nfomation nhs couse lensed for your personal use and shall not be wansfred coped or dstibutd without the authors peor witen const Jane MeLelland 2020Module 12 Did you take any sort of sleeping ald? ‘Confidential, For personal use only. Yee / No Name How would you describe the severity ofthe fatigue you are experiencing today? (0 = None, 10 = Severe) 0-10 How would you describe your interest level in physical activity today? Very high Good Low Nointerest Theinfomationin this couneisicensed for your prone we andshal not be transfered copie a distributed without the author’ prior writen consent ee. © Jane MeLelland 2020Confidential For personal use only. Module 12 Home Exercise Log Monday | Tuesday | Wednesday | Thursday Friday Saturday sunday swating | -watking | - waking | -wating | -watking | -watking | Watking oe Bicyeing | -Bieycing = Beyetng | -Bleyetng | -Bleyetng | -Bicyeing | -Bleyeung 7 other other +Other Other other +Other +Other “Time minutes) ‘Average tartrate RPE(6- 20) Comments Thelnfoomation nti couse censedforyour personal use and sal not be vansfented coped dstibuted without the autho’ peor wien consent © Jane MeLelland 2020 8Module 12 Ifyou are planning becoming more physically active, start by answering the seven questions below Please read the questions carefully and ‘answer them honestly. Check YES or NO, yes NO yes NO yes NO yes NO Yes NO Yes NO yes NO Confidential For personal use only. 4. Has your doctor ever said that you have a heart condition and that you should only do physical activity as recommended by a doctor? 2, Do you fee! pain in your chest when you do physical activity? 3.In the past month, have you had chest pain when you were not doing physical activity? 4, Do you lose your balance because of dizziness or do you ever lose consciousness? '5, 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? 6 ts your doctor currently prescribing drugs (for example, water pis) for your blood pressure ora heart ‘condition? 7.Do you know of any other reason why you should not do physical activity? © Jane MeLelland 2020Module 12 IF YOU ANSWERED Confidential For personal use only. YES to one or more questions and follow his/her advice. ‘Talk with your doctor by phone orn person BEFORE you start becoming much more physically active or BEFORE youhave a finess appraisal Tell your doctor about the questions you have answered YES to + You may be able to do any activity you want - as long as you start sloudy and bulld up gradually. Or, you may need to restrict ‘your activities to those which are safe for you to do. Talk with your doctor about the kinds of activites you wish to participate in + Find out which community programs are safe and helpful for you. NO to all questions If you answered NO honestly to all questions. you can be reasonably sure that you can: + Start becoming much more physically active - begin slowly and build up gradually This s the safest and easiest way to go. + Take part in a fines appraisal - this is an excellent way to dotermine your basic fitness 90 that you can plan the best way for you to live actively. is also highiy recommended that you have your blood pressure evaluated if your reading is over 144 /o4. talk with your doctor before you start becoming much mere physically active, ea | deLay BECOMING MUCH MoRE AcTIvE: = you are mt elng well because oF eporery ines suchas ool ora fre went you foo beter “i you eer may be regent tak to your docer before you sat bcomang mee are PLEASE NOTE: lFyourhealth changes so that you then answer YES to any of the questions tell your fitness or health professional. Ask ‘whether you should change your physical activity plan. If in any doubt after completing this questionnaire, consult your doctor BEFORE starting any physical activity or having a Stness appraisal Theinfomatonintiscoureisicensedforyour persanal use and sal nt be transfered copied or dstibuted without the suthor’s prior writen consent © Jane MeLelland 2020 8