054-755-3399

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054-755-3399            

Physical Activity Readiness Questionnaire

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First Name(*)

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E-mail(*)

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Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?(*)

Yes

No

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Do you feel pain in your chest when you do physical activity?(*)

Yes

No

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

Yes

No

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I agree to waiver and release of liability(*)

Yes

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Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?(*)

Yes

No

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Is your doctor currently prescribing drugs for your blood pressure or heart condition?(*)

Yes

No

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Do you know of any other reason why you should not do physical activity?(*)

Yes

No

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Barre Core Studio - Efrat

23/1 Mattiyahu HaCohen (basement entrance)

054-755-3399

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