PAR Q - Physical Activity Readiness Questionnaire

Your Details

First Name*

Mobile Number*

Last Name*

E-mail address*

DOB (**/**/***)*

Address*

Please read each question carefully and answer honestly by ticking YES or NO

PARQ FORM 1. Has your Doctor ever said that you have a heart condition?

Yes
No

If you answered YES to Q1 above, has your Doctor said that you should only do physical activity recommended by a Doctor?

2. Do you feel pain in your chest when you do physical exercise?

Yes
No

If you answered YES to Q2 above, please give details.

3. In the past month, have you had chest pain when you were NOT doing physical activity?

Yes
No

If you answered YES to Q3 above, please give details.

4. Whilst NOT performing exercise, do you lose balance because of dizziness or do you ever lose consciousness?

Yes
No

If you answered YES to Q4 above, please give details.

Questionnaire continued

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?

Yes
No

If you answered YES to Q5 above, please give details.

6. Is your doctor currently prescribing medication for your blood pressure or heart condition?

Yes
No

If you answered YES to Q6 above, please give details.

7. Do you know of any other reason why you should not take part in physical activity?

Yes
No

If you answered YES to Q7 above, please give details.

8. Are you pregnant or have you given birth in the last 6 months?

Yes
No

IF YOU HAVE ANSWERED YES TO ONE OR MORE QUESTIONS:Talk to your Doctor by phone or in person before you start becoming more physically active. Tell your doctor about the questionnaire and which question you answered yes to.

IF YOU HAVE ANSWERED NO TO ALL QUESTIONS:You can be reasonably sure you can start to become more physically active and take part in a suitable exercise programme.

Please list below any medical conditions that you have.

Please list below any medications that you currently take.

Emergency Contact Details

First Name*

Contact number*

Last Name*

Their relationship to you*

Your GP Details

GP Name*

GP Telephone Number*

GP Address*

Declaration

NOTE:

Please ensure that you have read and understand the relevant Booking Policy for the class that you are attending, as you are required to agree to these terms when attending a class.

I can confirm that I have read the relevant class booking policy and agree to the terms.

I confirm I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury. Any questions I had were answered to my full satisfaction.

I will inform the instructor of any new or unusual symptoms; changes in my medication; results of any investigations or treatment.

I also agree to my GP being contacted if deemed necessary & to share health information with my chosen clinician if need be.

Signature (please type your name)*

Date*

Date

PAR Q - PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

PAR Q - Physical Activity Readiness Questionnaire

Your Details

Please read each question carefully and answer honestly by ticking YES or NO

Questionnaire continued

Emergency Contact Details

Your GP Details

Declaration