Birthday*

Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke?*

Do you ever experience unexplained pains or discomfort in your chest at rest or during physical activity/exercise?*

Do you ever feel faint, dizzy or lose balance during physical activity/exercise?*

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months?*

If you have diabetes (type 1 or 2) have you had trouble controlling your blood sugar (glucose) in the last 3 months?*

Do you have any other conditions that may require special consideration for you to exercise?*