STAY STRONG

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

Country

(###)

###

####

How many meals (including snacks) do you eat per day? *

2

3

4

5

6 or more

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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? *

Yes

No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes

No

Do you know of ANY OTHER REASON why you should not do physical activity? *

Yes

No

Please review and agree to our policies detailed below (links found in footer). *

Check both boxes

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