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1. Has your doctor ever said that you have a heart condition?
Yes
No
2. Has your doctor ever said you have high blood pressure?
Yes
No
3. Do you feel pain in your chest at rest, during your daily activities of living, or when you do physical activity?
Yes
No
4. Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?
Yes
No
5. Have you ever been diagnosed with another chrinic medical condition (other than heart disease or high blood pressure)? If yes, list below.
Yes
No
6. Do you currently have (or have had within the past 12 months) a bone, joint, or soft tissue (muscle, ligament, or tendon) problem that could be made worse by becoming more physically active? Please answer no if you had a problem in the past, but does not limit your current ability to be physically active. If yes, list below.
Yes
No
7. Has your doctor ever said that you should only do medically supervised physical activity?
Yes
No
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