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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 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? *

Is your doctor currently prescribing drugs for your blood pressure or heart conditions? *

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? *

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

If yes, please explain below:

If you are signing up for PAYG, how often would you like to be billed?