Readiness Questionnaire

First Name: Last Name: Company: 1. Are you currently on any temporary or permanent medical restrictions? 2. Are you restricted from lifting, pulling or reaching by any physician? 3. Are you pregnant? Please indicate if you have or have had any of the following: Neurological Disorders & Conditions 4. Brain/Spinal injuries or disorders? 5. Seizures, epilepsy? 6. Ear disorders causing loss of balance? 7. Neuromuscular disease (Multiple Sclerosis,Muscular Dystrophy, Guillian Barre, Myasthenia Gravis)? 8. Stroke or paralysis? Cardiovascular/Pulmonary Disorders & Conditions 9. Recently experienced chest discomfort with exertion or shortness of breath for no apparent reason? 10. Heart disease, heart attack or other cardiovascular condition? 11. Heart surgery? Musculoskeletal Disorders and Conditions 12. Injury or surgery to your hip, leg, knee, ankle or foot that limits your abilities? 13. Chronic back pain, back surgery, disc disease, back injury or strain that limits your abilities? 14. Chronic neck pain, neck surgery, disc disease, neck injury or strain that limits your abilities? 15. Shoulder pain or surgery that limits your arm abilities? 16. Injury or surgery to your hand, wrist or elbow that limits your abilities? 17. Have you had a hernia or hernia surgery? 18. Is there a physical reason not mentioned here why you should not perform these tests, even if you wanted to? If "yes" to any questions, please explain. What was the date of your last physical exam? Applicant's Electronic Signature Date 

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