Get Active Table

1. Have you experienced ANY of the following (A to F) within the past six months?

A) A diagnosis of/treatment for heart disease or stroke, or pain/discomfort/pressure
in your chest during activities of daily living or during physical activity?
No
B) A diagnosis of/treatment for high blood pressure (BP), or a resting BP of 160/90 mmHg or higher? No
C) Dizziness or lightheadedness during physical activity? No
D) Shortness of breath at rest? No
E) Loss of consciousness/fainting for any reason? No
F) Concussion? No
Do you currently have pain or swelling in any part of your body (such as from an injury,
acute flare-up of arthritis, or back pain) that affects your ability to be physically active?
Yes
Has a health care provider told you that you should avoid or modify certain types of physical activity? Yes
Do you have any other medical or physical condition (such as diabetes, cancer, osteoporosis,
asthma, spinal cord injury) that may affect your ability to be physically active?
Yes


I am comfortable with becoming more physically active on my own without consulting a health care provider or QEP.