Name *

First Name

Last Name

Do you have a heart condition and should only do physical activity recommended by a physician? *

Yes

No

When you do physical activity, do you feel pain in your chest? *

Yes

No

When you were not doing physical activity, have you had chest pain in the past month? *

Yes

No

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

Yes

No

Do you have a joint or bone problem that may be made worse by a change in your physical activity? *

Yes

No

Is a physician currently prescribing medications for your blood pressure or heart condition? *

Yes

No

Are you pregnant? *

Yes

No

Do you know of any other reason you should not exercise or increase your physical activity? *

Yes

No

I consent to Fit Mná using my image on social media and online *

Yes

No

Date

MM

DD

YYYY