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1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
2. Do you feel pain in your chest when you do physical activity?
Yes
No
3. In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
4. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Yes
No
6. Is your doctor currently prescribing drugs for your blood pressure or heart condition?
Yes
No
7. Do you know of any other reason why you should not do physical activity?
Yes
No
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