YES NO

1. Has your doctor ever said that you have a heart condition and
recommended physical activity only under medical supervision?

2. In the past month, have you had pain in your chest when you are
physically inactive or active?

3. Do you have problems in breathing when you are physically inactive

or active?

4. Did you ever fall because of dizziness or have you ever lost
consciousness?

5. Do you have bone or joint problems that could be made worst when
you are physically active?

6. Has a doctor ever prescribed you of drugs for high blood pressure or
heart or breathing problems?

7. Do you know any other reason why you should not do physical
activity?