Follow-Up Survey

This survey is a pre-screening questionnaire for our Muscle Health Study.  Please complete the survey as accurate as possible.  All information will be kept in confidential.  The eligibility status of your study participation will be notified by email.

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* 1. What is your email address?

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* 2. What is your age? ______ (years of age)

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* 3. Do you have a personal history of any of the following diseases?  Please check the appropriate box(es).

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

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

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

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

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* 8. 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?

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

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* 10. Do you know of any other reason you should not do physical activity?

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