Name *

First Name

Last Name

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

No

Other | to discuss

Do you feel pain in your chest when you perform physical activity? *

Yes

No

Other | to discuss

In the past month, have you had chest pain when you were not performing any physical activity? *

Yes

No

Other | to discuss

Do you lose your balance because of dizziness, or do you ever lose consciousness? *

Yes

No

Other | to discuss

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes

No

Other | to discuss

Is your doctor currently prescribing any medication for your blood pressure or a heart condition? *

Yes

No

Other | to discuss

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

Yes

No

Other | to discuss

How did you hear about us? *

Social Media

Someone Referred Me

Our Website

A Google Search

Poughkeepsie Tennis Club

Other