Health Questionnaire

Do you have, or have had:

High Blood Pressure

Heart Disease

Lung Disorder (e.g. asthma, emphysema)

High Cholesterol

Diabetes

Other Cardiac Problem

None

Have you ever been told you are at risk of:

Have you ever been told that you have heart problems, e.g:

Do you have, or have you experienced:

Do you experience sudden shortness of breath?

Yes

No

Do you take any medications for (please name):

Do you ever had pain or pressure either at rest or during exercise:

in the middle of, or on the left side of, the chest

in the neck region

at the left shoulder or down the left arm

None

Are you aged over 60 years of age:

Yes

No

Do you have any other conditions or injuries that may affect your ability to train:

Yes

No

Do you have any joint or muscular problems that may affect your ability to train:

Yes

No