Self-administered health questionnaire

The application of this questionnaire aims at helping you carry out a safe physical activity program. Mark with an X the affirmative answers for each of the items.

Name:

Age:

Birth date Age:

Occupation Shift:

Turno:

Physical Activity or sport:

Weekly frequency:

Have you suffered or are you suffering any of the following diseases or health conditions:

Heart disease	Lung disease
Heart murmur	Lack of air
Abnormally rapid heartbeat	Extreme tiredness
Chest pain	Unconsciousness
Cardiac Blowing	Tromboflebitis
High pressure	Leg oedema (swelling)
Abnormally rapid heartbeat	Heart beats

Do you have any of the following heart risk factors?

Smoker	Diabetic
Heart murmur	Lack of air
High level of cholesterol	Male over 45
Overweight/Obesity	Female over 55
Sedentary
Parents or brothers death due to heart attack or younger than 45.

If you had negative answers for some of the questions on item I, or if you have 2 or more risk factors:
YOU CAN BE PART OF A PROGRESSIVE PHYSICAL ACTIVITY PROGRAM

If you had positive answers to any of the questions on item I, or if you have 2 or more risk factors:
YOU MUST GO TO THE DOCTOR BEFORE STARTING THE PHYSICAL ACTIVITY PROGRAM

If you have never had a medical check and is unaware of the existence of a risk factor:
YOU MUST BE EVALUATED BY A DOCTOR BEFORE STARTING THE PHYSICAL ACTIVITY PROGRAM

If you will start the physical activity program for altitude:
YOU MUST BE EVALUATED BY A DOCTOR ACQUAINTED WITH PHYSICAL ACTIVITY AND ALTITUDE.

(Adapted from DIGEDER’s Recommendations for Heath Physical Activity)