Today's Date *

MM

DD

YYYY

Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Emergency Contact Number *

(###)

###

####

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

No

Do you feel pain in your chest when performing physical activity? *

Yes

No

Have you experienced chest pain when NOT performing physical activity in the last month? *

Yes

No

Do you lose your balance because of dizziness or have you lost consciousness recently? *

Yes

No

Do you have any bone or joint problems such as arthritis or osteoporosis, which could be aggravated through physical activity? *

Yes

No

Do you have/have you had any back or disc related issues which could be aggravated through physical activity? *

Yes

No

Do you have/have you had glaucoma or any other eye issues? *

Yes

No

Is your doctor currently prescribing you medication for high blood pressure or a heart condition? *

Yes

No

Have you had an operation in the last 12 months? *

Yes

No

Is there any reason why you should NOT participate in physical activity? *

Yes

No

Are you currently pregnant or have you given birth or experienced pregnancy loss within the last six weeks? *

Yes

No

DECLARATION *

IMPORTANT: If you answered YES to any of the questions above, you will need to seek medical advice and guidance from your doctor before proceeding with physical activity. If you answered NO to all of the above questions, you can be reasonably sure you can exercise safely and have a low risk of having any medical complications from exercise. Please note - if your health changes so that you subsequently answer YES to any of the above questions, please inform the provider immediately. It is your responsibility to keep the provider informed of any relevant health changes so that they can amend/change your fitness programme.This PAR-Q is valid for 12 months from date of completion. It becomes invalid if your condition changes so that you would answer YES to any of the questions. Your declaration: I have read, understood and accurately completed this questionnaire. I confirm that I am engaging in an acceptable level of exercise, and my participation involves a risk of injury. Where necessary, I have sought medical advice and my GP has agreed that I may exercise.

I agree