HIIT Transformation Readiness Questionnaire


​​Contraindications
The program is intended for people who do not have any contraindications or significant health problems. There are times Heart Rate (HR) may be elevated beyond usual exercise prescription. For example, a typical exercise HR range might be Lower 65% to Upper 85% of (220-Age) = HR in Beats Per Minute (bpm). If the participant is 40 years old it would look like this, 220 – 40 = 180 Max. 180 x 65% = 117 bpm Lower and 180 x 85% = 153 bpm Upper. HR may exceed this upper level for short periods of time particularly in the later part of the program. Those interested in participating in the program must read and answer the questions and comments below to determine if this program is right for them. Prior to consideration candidates must complete, sign and return the document.

Physical Activity Fun and Healthy
Regular physical activity is fun and healthy and increasingly people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming more physically active or participating in this program or any other exercise program. If you are planning to participate in this program or simply become much more physically active, start by answering the questions below. If you are between the ages of 15 and 69 these questions will help you determine if this program is right for you and tell you if you should talk to your doctor before you start. Common sense is you best guide when you answer these questions.

Questionnaire
Please read the questions carefully and answer each one honestly: Answer Yes or No.
1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
2) Do you feel pain or tightness in your chest when you do physical activity?
3) In the past month, have you had chest pain or tightness when you were not doing physical activity?
4) Do you lose your balance because of dizziness or do you ever lose consciousness?
5) 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?
6) Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
7) Is your Blood Pressure reading over 144/94?
8) Do you know of any other heart conditions or physical reasons why you should not participate in this program or do physical activity?
9) Are you pregnant or think you might be pregnant?
10) Are you over 69 years old?


If you answered YES to one or more questions:
This program may not be right for you at this time. BEFORE you begin this program tell your doctor about this program and which questions you answered YES. BEFORE you are allowed to participate in this program your doctor will need to provide a medical release and approve you to participate in this program. Also, if you answered YES to any of the questions you should talk with your doctor BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal.

While this program may not be right for you at this time, 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 with your doctor about this program or the kinds of activities you wish to participate in and follow his/her advice.

There are many different fitness programs available. Find out which community programs are safe and helpful for you and get moving on your fitness journey.

If you answered NO to all questions:

You can be reasonably sure that you can participate in this program or start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.

However, even if you answer NO to all questions you should delay participating in this program or becoming much more active if you are not feeling well because of a temporary illness such as a cold or fever – wait until you feel better.

I have read and understood this document and answered all of the questions honestly. Any questions I had were answered to my full satisfaction. If I have answered NO to all of the questions or if I answered YES to any questions I have discussed this program and this document with my doctor and received a medical release and approval from my doctor to participate in this program. Once I am accepted and enrolled in the program, I am fully committed to participate in this program to the best of my ability as detailed above.

Name:                                                                     Date:                                         
                
Signature:                                                                  


Witness: