CardioCoach PRO User Manual | Page 106
Participant Activity Readiness Questionnaire
1. Has a doctor ever said you have a heart condition and that you should only
do physical activity recommended by a doctor?
Yes ¨ No ¨
2. Do you feel pain in your chest when you do physical activity?
Yes ¨ No ¨
3. In the past month, have you had chest pain when you are not doing
physical activity?
Yes ¨ No ¨
4. Do you lose your balance because of dizziness or do you ever lose
consciousness?
Yes ¨ No ¨
5. Is your doctor currently prescribing drugs (for example, water pills) for
your blood pressure or heart condition?
Yes ¨ No ¨
6. Do you have a bone or joint problem that could be made worse by a change
in your physical activity?
Yes ¨ No ¨
7. Do you know of any other reason why you should not do physical activity?
Yes ¨ No ¨
**If you are over 69 years of age, and you are not used to being very active, check
with your doctor.
Medications
Please list all medications (including herbs and vitamins) that you are currently
taking:
Name of Medication: Dosage: Taken for:
Do any of your medications affect your heart rate? If you are uncertain, please
consult your physician.
_______________________________________________________________________________
_______________________________________________________________
I have reviewed these questions and answered them to the best of my ability. I
understand that these materials will be reviewed and I may be asked to see my
doctor before participating.
Date of Birth: ________________________ Age: _______________
Signature: ___________________________ Date: _______________
Print name: ___________________________
Witness Signature: _____________________________________
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