Rise Health Questionnaire

To help us adapt and personalise your session and make sure they are suitable for you please fill out the below questions.

Name

First Name

Last Name

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

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

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose balance because of dizziness or do you ever lose consciousness?

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?

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Do you know of any other reason why should not take part in physical activity?

If you answered 'Yes' please give further detail as well as confirming your GP is aware and has signed you off to complete exercise? (if you answered 'yes' but have not consulted your GP please do so before taking part in exercise)

I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. I understand by clicking 'agreed' below this is in replacement of your digital signature.

Date

YYYY

Rise Health Questionnaire

RISE/FITNESS - Find your own version of greatness