Physical Activity Readiness (PAR-Q)
Fitness Questionnaire
Name
First Name
Last Name
Email
example@example.com
Phone Number
Next of Kin
First Name
Last Name
Phone contact details
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
Do you suffer from any social or behavioural issues due to neurological diverse conditions such as Autism, Attention Deficit, Bipolar or Aspergers Syndrome?
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
Have you travelled to or from any areas currently showing to have experienced a high level of Coronavirus infection?
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:
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.
Signed
Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise.
Signed
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
1
Submit
Should be Empty: