COHORT WAIVER and PEQ Please Submit forms 1 & 2

Please fill out the PEQ below:

Have you ever had a heart attack, coronary revascularisation surgery, or a stroke? *
Has your doctor ever told you that you have heart trouble or vascular disease? *
Has your doctor ever told you that you have a heart murmur? *
Do you ever suffer from pains in your chest, especially during exercise? *
Do you ever get pains in your calves, buttocks, or back of your legs during exercise that is not due to soreness or stiffness? *
Do you ever feel faint or have spells of severe dizziness, especially during exercise? *
Do you experience swelling or accumulation of fluid around the ankles? *
Do you ever feel your heart is suddenly beating faster, racing or skipping beats, either at rest or during exercise? *
Do you have chronic obstructive pulmonary disease, interstitial lung disease, or cystic fibrosis? *
Have you ever had an attack of shortness of breath that developed when you were not doing anything strenuous at any time in the last 12 months? *
Have you ever had shortness of breath that developed after you stopped exercising at any time in the last 12 months? *
Have you ever been woken at night by an attack of shortness of breath at any time in the last 12 months? *
Do you have diabetes [IDDM or NIDDM]? If so, do you have trouble controlling your diabetes? *
Do you have any ulcerated wounds or cuts on your feet that do not seem to heal? *
Do you have any liver, kidney, or thyroid disorders? *
Do you experience unusual fatigue or shortness of breath when doing everyday activities? *
Do you smoke or have you quit in the last two years? *
Have any family member had a heart attack or suffered from any cardio vascular disease? *