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

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

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

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

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

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

Do you know of any other reason why you should not do physical activity? If you answered yes to any of the above please go into more detail below.