Physical Activity Readiness (PAR-Q)
Fitness Questionnaire
Name
*
First Name
Last Name
Date of Birth
*
Email
*
example@example.com
Phone
*
Emergency contact information
*
First Name
Last Name
Contact phone
*
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had a chest pain when you were not doing physical activity?
*
Yes
No
Do you lose you balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem (for example, back, knee, hip) that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing medication for your blood pressure or heart condition?
*
Yes
No
Are you currently taking any regular form of medication?
*
Yes
No
Do you know of any other reason why you should not do physical activity?
*
Yes
No
If you have answered YES to one or more of the above questions please comment fully in the box provided:
Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise.
*
Digital Signature
Is there anything else you think I should know?
I have read, understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.
*
Digital Signature
Date:
*
Submit
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