- I have had problems with my lungs or breathing, heart or blood YesNo
- Thoracic surgery, heart valve surgery, stent placement, or pneumothorax (collapsed lung). YesNo
- Asthma, wheezing, severe allergies, hay fever, or congested airways in the last 12 months that limits my physical activity or exercise. YesNo
- A problem or illness involving my heart such as: angina, chest pain on exertion, heart failure, pulmonary edema, cardiomyopathy, or stroke, or I am taking medication for any heart condition. YesNo
- o Recurrent bronchitis and persistent cough in the last 12 months, or have been diagnosed with emphysema. YesNo
- I am over 45 years old YesNo
- I find it difficult to perform moderate exercise (for example, walking 1.6 kilometers in 12 minutes or swimming 200 meters without resting), or I have not been able to participate in normal physical activity due to fitness or health reasons in the last 12 months. YesNo
- I have had problems with my eyes, ears, or nasal passages or sinuses YesNo
- I have had surgery in the last 12 months, or have ongoing problems related to a previous surgery YesNo
- I have lost consciousness, had migraine headaches, seizures, stroke, significant head injury, or sustained neurological injury or disease YesNo
- I have had psychological problems, been diagnosed with a learning disability, personality disorder, panic attacks, or drug or alcohol addiction YesNo
- I have had back problems, hernia, ulcers or diabetes YesNo
- I have had stomach or intestinal problems, including recent diarrhea YesNo
- I am taking prescription drugs (with the exception of birth control or antimalarial drugs) YesNo