Physical Activity Readiness Questionnaire  

Please read the following questions carefully and take note of any question you may respond to with a YES.

Self-completion of this questionnaire is required for all WellWorks members to ensure they are able to safely participate in our offerings. WellWorks will not retain a copy of your responses. 

  Yes No
Has a doctor ever said that you have a heart condition and/or irregular rhythm and that you should only do physical activity recommended by a doctor?       
Do you feel pain or discomfort in your chest when you do physical activity?     
In the past month, have you had chest pain or chest discomfort when you were not doing physical activity?    
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 have diabetes, renal disease, or other metabolic disease and you do not already exercise regularly?     
Do you have uncontrolled asthma, COPD, interstitial lung disease, or cystic fibrosis?     
Do you know of any other reason why you should not do physical activity?     

If you answered "YES" to any question, there may be a medical contraindication to your participation in exercise at this time.  Talk with your doctor BEFORE you start becoming more physically active.  Tell your doctor which question(s) you answered YES.  You may be able to do any activity you want—as long as you start slowly and build up gradually.  Or, you may need to restrict your activities to those which are safe for you.  Talk to your doctor about the kinds of activities you wish to participate in and follow his/her advice.      

All members are required to consent to the following statement by completing the Membership Agreement Waiver upon membership sign-up: I, my heirs, executors, administrators and assigns, waive and release any and all of my rights and claims for damages I may have against Ohio University, WellWorks, and their officers, agents, sponsors, and employees for any and all injuries suffered during the visit.  I understand that certain risks exist by participating in the program and I have knowledge of these risks.