Readiness for exercise assessment

Registration and Readiness for Exercise Questionnaire

In order to check the suitability of the PBP course for your individual needs, we need first to get some basic understanding of your current state of health and level of fitness, so as well as providing basic contact details we ask that you complete a “Readiness for exercise” questionnaire, at the bottom of this page. (please see below)

Most adults are able to take part in physical activity and fitness programmes. However for some people there may be specific problems that could be aggravated by exercising or they could potentially be at risk because of a medical problem.

Please fill out the registration and the questionnaire to the best of your knowledge. The questionnaire is intended as a snapshot look at any risk factors that you may have before you take part in PowerBell Pump and whether or not it is going to be appropriate for you at your present level of health. Common sense is your best guide in answering these questions.

Please read and answer the questions carefully. If your form is clear we will contact you with dates, venues and availability. If the form is not clear we will advise you further.

DETAILS:

First name*

Last name*

Email*

Your email address remains securely with us,
see Privacy.

Phone number*

VENUE:

* required fields

READINESS FOR EXERCISE QUESTIONNAIRE

Please answer all questions

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

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

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

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

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

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

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

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

9. If yes, could it be made worse by a change in your physical activity?

10. Do you have any back problems or have you ever been told you have swayback, kyphosis, lordosis or flatback?

11. Are you currently taking any prescribed medication?

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

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

14. If yes, please tell us more here:

15. What is your current exercise time per week?*

Male Female

Nickname (for use on monitor software)

Weight (kg)

Height (feet and inches)

Date of Birth

- 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”