9) Do [Type
you take
here]medications on a daily basis? Y/N
If yes, reasons why:
10) Have you recently been hospitalized? Y/N
If yes, reasons why:
How long for:
11) Do you smoke? Y/N
If yes, how often?
12) Do you drink alcohol? Y/N
If yes, how often?
13) Do you have any other illness, or injury which may be aggravated by regular exercise? Y/N
14) Are you currently, or have been pregnant in the last six months? Y/N
15) Is there other reasons why you should not do physical activities? Y/N
If yes, what are they:
Name:
Signature:
Signature of parent:
Date:
you take
here]medications on a daily basis? Y/N
If yes, reasons why:
10) Have you recently been hospitalized? Y/N
If yes, reasons why:
How long for:
11) Do you smoke? Y/N
If yes, how often?
12) Do you drink alcohol? Y/N
If yes, how often?
13) Do you have any other illness, or injury which may be aggravated by regular exercise? Y/N
14) Are you currently, or have been pregnant in the last six months? Y/N
15) Is there other reasons why you should not do physical activities? Y/N
If yes, what are they:
Name:
Signature:
Signature of parent:
Date:
