MET-Q MET-Q FormAll information is strictly confidential. Name * First Name Last Name Email * Phone * (###) ### #### Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by your doctor? * YES NO Do you feel pain in your chest when you do physical activity? * YES NO In the past month, have you had chest pain when you were not doing physical activity? * YES NO Do you lose your balance because of dizziness or do you ever lose consciousness? * YES NO Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity? * YES NO Please check all that apply or if ever experienced: Dizziness / Syncope Unexplained weight loss Shortness of Breath / Chest Pain Changes in Bowel / Bladder habits Blood in Stool Change in a mole or patch of skin Visual Field Changes Loss of Consciousness / Orientation Abnormal Vital Signs Past History of Cancer Night Sweats Night Pain Drug Abuse None Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? * YES NO Do you know of any other reason why youshould not do physical activity? * YES NO Sign Here to Acknowledge the below: * If you answered “Yes” to one or more of the above questions, consult your physician before engaging in physical activity. Tell your physician which questions you answered “Yes” to. After a medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition. Thank you! Your trainer will be in touch to further discuss during your initial consult.
