DOB Gender Male Female Other Contact Number Has a doctor or medical professional ever diagnosed you with a heart condition and suggested you restrict your levels of physical activity No Yes When you perform physical activity, do you feel pain in your chest? No Yes Have you experienced chest pain in the past month? No Yes Do you ever faint or get dizzy and lose your balance? No Yes Do you have an injury or orthopaedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity? No Yes Do you have high blood pressure or a heart condition in which a doctor/medical professional is currently prescribing medicine? No Yes Are you pregnant? No Yes Do you have insulin dependant diabetes? No Yes Are you 69 years of age or older and not used to being very active? No Yes Are there any other reason you should not exercise or increase your physical activity?