LIGHTSPEED RUNNING
PHYSICAL ACTIVITY READINESS

Name, Age, and Daytime Telephone Number:
                                                                                                                                                    

Street Address:
                                                                                                                                                    

City, State and Zip:
                                                                                                                                                    

Height and Weight:
                                                                                                                                                    

How often do you run?
                                                                                                                                                    

In case of emergency, whom would you like us to contact? (Name, relationship and telephone)
                                                                                                                                                    

Please list all major injuries which you have had in the past ten years that affected your ability to exercise safely:
                                                                                                                                                    

                                                                                                                                                    

1.    Has your doctor ever said you have heart trouble?
Circle One: Yes  No

2.    Do you frequently have pains in your heart and chest?
Circle One: Yes  No

3.    Do you often feel faint or have spells of severe dizziness?
Circle One: Yes  No

4.    Has a doctor ever said your blood pressure was too high?
Circle One: Yes  No

5.    Has your doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
Circle One: Yes  No

6.    Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?
Circle One: Yes  No

7.    Are you over age 65 and not accustomed to vigorous exercise?
Circle One: Yes  No

Signature and Date:

                                                                                                                                                

©2005 LSR, Inc.