Back to Fitness Programme Page1 / 1 100% of survey complete. Question Title * 1. Address Name * Company Address * Address 2 City/Town State/Province ZIP/Postal Code * Email Address * Phone Number * Question Title * 2. What is your date of birth? D.O.B Date Question Title * 3. Please read the questions carefully and answer each one honestly. Check the box if the answer is "yes". a) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? b) Have you ever felt pain in your chest when you do physical exercise? c) In the past month, have you had chest pain when you were not doing physical activity? d) Do you often feel faint, have spells of severe dizziness or have lost consciousness? e) Have you ever suffered from unusual shortness of breath at rest or with mild exertion? f) Do you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or that may be made worse by exercise? g) Do you have either high or low blood pressure? h) Are you currently on any prescribed medicines that may affect your ability to exercise? i) Are you pregnant or have you had a baby in the last 6 months (females only)? j) Do you know of any other reason that would affect your ability to participate in physical activity? Question Title * 4. If you answered "yes" to questions 3g, 3h or 3j above, please give details. Question Title * 5. Have you ever done any structured exercise? If so, what did you do? What type of exercise do you enjoy most and what do dislike most? Question Title * 6. Do you have any injuries or health conditions, not mentioned above that may affect your ability to exercise? Question Title * 7. What would you say are the main barriers preventing you from exercising? Lack of facilities No time No motivation Injury/illness Family Work Lack of knowledge Confidence Other (please specify) Question Title * 8. I can confirm that I have answered all questions honestly and that the information given is correct Yes No Question Title * 9. I give permission to be added to the VRPT mailing list (you may unsubscribe at any time) Yes No Done