2. Do you feel pain in your chest at rest, during your daily activities of living, OR when you do physical activity? *

Yes

No

3. Do you lose balance because of dizziness OR have you lost consciousness in the last 12 months? Please answer NO if your dizziness was associated with over-breathing (including during vigorous exercise). *

Yes

No

1. Do you have Arthritis, Osteoporosis, or Back Problems? If NO ☐ go to question 2 If the above condition(s) is/are present, answer questions 1a-1c

Yes

No

1a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments.)

Yes

No

1b. Do you have joint problems causing pain, a recent fracture or fracture caused by osteoporosis or cancer, displaced vertebra (e.g., spondylolisthesis), and/or spondylolysis/pars defect (a crack in the bony ring on the back of the spinal column)?

Yes

No

1c. Have you had steroid injections or taken steroid tablets regularly for more than 3 months?

Yes

No

2. Do you currently have cancer of any kind?
If the above condition(s) is/are present, answer questions 2a-2b.

Yes

No

2a. Does your cancer diagnosis include any of the following types: lung/bronchogenic, multiple myeloma (cancer of plasma cells), head, and/or neck?

Yes

No

2b. Are you currently receiving cancer therapy (such as chemotherapy or radiotherapy)?

Yes

No

3. Do you have a Heart or Cardiovascular Condition? This includes Coronary Artery Disease, Heart Failure, Diagnosed Abnormality of Heart Rhythm.
If the above condition(s) is/are present, answer questions 3a-3d

Yes

No

3a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments.)

Yes

No

3b. Do you have an irregular heartbeat that requires medical management? (e.g., atrial fibrillation, premature ventricular contraction)

Yes

No

3c. Do you have chronic heart failure?

Yes

No

3d. Do you have diagnosed coronary artery (cardiovascular) disease and have not participated in regular physical activity in the last 2 months?

Yes

No

4. Do you currently have High Blood Pressure?
If the above condition(s) is/are present, answer questions 4a-4b.

Yes

No

4a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies?

Yes

No

4b. Do you have a resting blood pressure equal to or greater than 160/90 mmHg with or without medication?

Yes

No

5. Do you have any Metabolic Conditions? This includes Type 1 Diabetes, Type 2 Diabetes, Pre-Diabetes
If NO, go to question 6

Yes

No

5a. Do you often have difficulty controlling your blood sugar levels with foods, medications, or other physician-prescribed therapies?

Yes

No

5b. Do you often suffer from signs and symptoms of low blood sugar (hypoglycemia) following exercise and/or during activities of daily living? Signs of hypoglycemia may include shakiness, nervousness, unusual irritability, abnormal sweating, dizziness or light-headedness, mental confusion, difficulty speaking, weakness, or sleepiness.

Yes

No

5c. Do you have any signs or symptoms of diabetes complications such as heart or vascular disease and/or complications affecting your eyes, kidneys, OR the sensation in your toes and feet?

Yes

No

5d. Do you have other metabolic conditions (such as current pregnancy-related diabetes, chronic kidney disease, or liver problems)?

Yes

No

5e. Are you planning to engage in what for you is unusually high (or vigorous) intensity exercise in the near future?

Yes

No

6. Do you have any Mental Health Problems or Learning Difficulties?
This includes Alzheimer’s, Dementia, Depression, Anxiety Disorder, Eating Disorder, Psychotic Disorder, Intellectual Disability, Down Syndrome. If the above condition(s) is/are present, answer questions 6a-6b

Yes

No

6a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

No

6b. Do you have Down Syndrome AND back problems affecting nerves or muscles?

Yes

No

7. Do you have a Respiratory Disease?
This includes Chronic Obstructive Pulmonary Disease, Asthma, Pulmonary High Blood Pressure. If the above condition(s) is/are present, answer questions 7a-7d

Yes

No

7a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Option 1

Option 2

7b. Has your doctor ever said your blood oxygen level is low at rest or during exercise and/or that you require supplemental oxygen therapy?

Yes

No

7c. If asthmatic, do you currently have symptoms of chest tightness, wheezing, laboured breathing, consistent cough (more than 2 days/week), or have you used your rescue medication more than twice in the last week?

Yes

No

7d. Has your doctor ever said you have high blood pressure in the blood vessels of your lungs?

Yes

No

8. Do you have a Spinal Cord Injury?
This includes Tetraplegia and Paraplegia If NO, go to question 9
If the above condition(s) is/are present, answer questions 8a-8c

Yes

No

8a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

No

8b. Do you commonly exhibit low resting blood pressure significant enough to cause dizziness, light-headedness, and/or fainting?

Yes

No

8c. Has your physician indicated that you exhibit sudden bouts of high blood pressure (known as Autonomic Dysreflexia)?

Yes

No

9. Have you had a Stroke?
This includes Transient Ischemic Attack (TIA) or Cerebrovascular Event If NO ☐ go to question 10 If the above condition(s) is/are present, answer questions 9a-9c

Yes

No

9a. Do you have difficulty controlling your condition with medications or other physician-prescribed therapies? (Answer NO if you are not currently taking medications or other treatments)

Yes

No

9b. Do you have any impairment in walking or mobility?

Yes

No

9c. Have you experienced a stroke or impairment in nerves or muscles in the past 6 months?

Yes

No

10. Do you have any other medical condition not listed above or do you have two or more medical conditions?
If NO ☐ go to the PARTICIPANT DECLARATION at the bottom of the page

Yes

No

10a. Have you experienced a blackout, fainted, or lost consciousness as a result of a head injury within the last 12 months OR have you had a diagnosed concussion within the last 12 months?

Yes

No

10b. Do you have a medical condition that is not listed (such as epilepsy, neurological conditions, kidney problems)?

Yes

No

Name *

First Name

Last Name

Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

I hereby declare that the information provided in this form is true and correct to the best of my knowledge and belief. I understand that any false statements or omissions may result in disqualification or termination of my application *

Yes, I understand