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physical activity readiness questionnaire

These questions help us to know more about you + your current state of health.
Thank you for answering clearly + honestly. Have a wonderful experience at the Gem.
If you have any questions, visit www.thegempdx.com for contact info + more.

Today's Date: November 16, 2019

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Primary physician name + number:
Has a physician ever said you have a heart condition?*
No
Yes
Has a physician ever said you should only do physician prescribed physical activity?*
No
Yes
When you do physical activity, do you feel pain in your chest?*
No
Yes
Have you had chest pain in the past month?*
No
Yes
Do you ever lose consciousness or do you lose your balance because of dizziness?*
No
Yes
Do you have a condition that may be made worse by physical activity?*
No
Yes
Is a physician currently prescribing medications for you?*
No
Yes
Do you have insulin dependent diabetes?*
No
Yes
Are you pregnant?*
No
Yes
Are you 69 years of age or older?*
No
Yes

Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. tell your doctor your intent to exercise and to which questions you answer yes. if you honestly answered no to all questions you can be reasonably positive that you can safely increase your level of physical activity gradually. if your health changes so you then answer yes to any of the above questions, seek guidance from a physician. your signature below attests to you and your physician's consent to a wellness class guided by Gem Wellness Center. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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