Physical Activity Readiness

Physical Activity Readiness Questionnaire (PAR Q)
This information is collected to ensure the health & safety of the participants readiness to enter into physical activity. All information collected will be safely stored for the duration of your membership with Paula Edmonds Pilates and destroyed safely upon completion. Please refer to the privacy policy on the website for further information.
Client Name:
Address:
Email:
example@example.com
Phone:
DOB:
MonthDayYear
Date
WHAT ARE YOU MAIN REASONS FOR STARTING A FITNESS PROGRAMME?
PLEASE TICK YES OR NO FOR THE QUESTIONS BELOW
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
Do you lose balance because of dizziness or ever lose consciousness?
Do you have a joint or bone problem (eg: knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not take part in physical activity?
If yes please give details:
If you answered YES to one or more questions:
You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.
If you answered NO to ALL of the questions:
It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.
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.
Signature:
Clear
Print name:
Date:
MonthDayYear
Date
Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise.
Note: This PAR Q becomes invalid should your condition change.
Should be Empty:

Physical Activity Readiness Questionnaire (PAR Q)

PLEASE TICK YES OR NO FOR THE QUESTIONS BELOW