First name*

Last name*

Email*

Your email address remains securely with us,
see Privacy.

Phone number*

VENUE: Bourton Mill Health & LeisureKidlington & Gosford Sports CentreWestminster Institute of EducationOXSRADBrookes Centre for Sport

* required fields

READINESS FOR EXERCISE QUESTIONNAIRE

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

2. Do you feel pains in your chest when you are involved in any form of physical activity?
NoYes

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

4. Do you suffer from asthma or any other respiratory disorders?
NoYes

5. Have you ever been told you have high blood pressure?
NoYes

6. Have you ever been told you have low blood pressure?
NoYes

7. Do you lose your balance because of dizziness or do you ever lose consciousness?
NoYes

8. Do you have a bone or joint problem (for example, back, knee or hip)?
NoYes

9. If yes, could it be made worse by a change in your physical activity?
NoDon't knowYes

10. Do you have any back problems or have you ever been told you have swayback, kyphosis, lordosis or flatback?
NoDon't knowYes

11. Are you currently taking any prescribed medication?
NoYes

12. If yes, please tell us about your medication.

13. Do you know of any other reason why you should not do physical activity?
NoYes

14. If yes, please tell us more here:

15. What is your current exercise time per week?*1 Light exercise, non-regularly2 Light exercise, regularly less than 1 hour3 Light exercise, regularly more than 1 hour4 Heavy exercise, regularly under 30 minutes per week5 Heavy exercise, regularly 30-60 minutes per week6 Heavy exercise, regularly 1 - 3 hours per week7 Heavy exercise, regularly 5 - 7 hours7.5 Heavy exercise, regularly 5 - 7 hours8 Heavy exercise, regularly 7 - 9 hours8.5 Heavy exercise, regularly 9 - 11 hours9 Heavy exercise, regularly 11 - 13 hours9.5 Heavy exercise, regularly 13 - 15 hours10 Heavy exercise, regularly over 15 hours

 Male Female

Nickname (for use on monitor software)


Weight (kg)


Height (feet and inches)


Date of Birth
01020304050607080910111213141516171819202122232425262728293031010203040506070809101112199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

- Statement: “I have read, understood and accurately complete this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise governed by heart rate training, and understand that my participation could involve a risk of injury”