Free Diet Plan and Workout Routine Personalization Form

• Has your doctor ever said that your have a heart condition and that you should only do physical activity recommended by a doctor?
• Do you feel pain in your chest when you do physical activity?
• In the past month, have you had chest pain when you were not doing physical activity?
• Do you lose your balance because of dizziness or do you ever lose consciousness?
• Do you have a bone or joint problem (for example, back, knee of hip) that could be made worse by a change in your physical activity?
• Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure of heart condition?
• Do you know of any other reason why you should not do physical activity?

Yes No