Chair-Based Exercise HEALTH CHECK FORM

ANY OF THE FOLLOWING SPEAK TO A DOCTOR BEFORE TAKING PART

  • Have you at any time been told you have heart trouble or are being treated for any heart condition
  • Have you had a heart attack in the last three years
  • Have you had chest pain while at rest/or during exertion
  • Have you experienced dizziness and/or fast, irregular or very slow heart beats
  • Have you got uncontrolled high blood pressure
  • Have you had diabetes for more than 10 years
  • Have you shortness of breath after exertion, at rest or even at night in bed
  • As an adult, have you ever had a fracture of the hip, spine or wrist
  • Have you arthritis or a joint problem
  • Have you pain in the buttocks, back of legs, thighs or calves during walking
  • Have you swollen ankles, feet, hands and /or take diuretics
  • Have you any lacerated wounds or cuts on the feet that are slow to heal
  • Have you had a fall more than twice in the past year
  • Have you been inactive for 3 years or more and are over 65
  • Are you intending to take up vigorous exercise
  • Have any condition, which is or becomes unstable