Physical Activity Readiness Questionnaire (Par-Q)

Full Name*

First NameLast Name

Email*

example@example.com

Phone Number

Area Code (00)Phone Number

Gender*

MaleFemale

Date of Birth*

MonthDayYear

Please write "NA" for any questions below that are not applicable to you.

If you have any diagnosed health problems or conditions, please list the condition(s).*

If you are on any medications, please list them.*

If there additional therapies being undertaken for the given health problem(s) please detail them?

If you have any muscular injuries, joint or bone problems that can be aggrivated by exercise, please list them.*

What additional therapies are being undertaken for the given injury, joint or bone problem?

Has anyone of your immediate family developed heart disease before the age of 60?*

YesNo

Do any diseases run in your family?*

YesNo

Do you suffer from diabetes, asthma, high or low blood pressure?*

YesNo

if yes please list:

Are you a smoker?*

YesNo

What following goals does best fit in with your goals?

Emergency Contact Name*

First NameLast Name

Emergency Contact Number*

Area CodePhone Number

1.) ASSUMPTION OF RISK

By agreeing below you state that you understand and have answered all the questions on this form honestly and that You realise that your participation in physical exercise can pose risk of injury and in some cases even the possibility of death. You hearby confirm that you are voluntarily engaging in physical activity and thus take full responsibility for you own personal wellbeing.

2.) MEDIA CONTENT

By aggreeing below you acknowledge that you are aware that on occasions Macclesfield Performance may take photographs or videos of the gym, classes and 121 sessions for promotional purposes and that on occasion you may be in these.

3.) ALL THE INFORMATION I HAVE GIVEN IS CORRECT

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential and that should anything in my medical circumstances change that I will inform Macclesfield Performance and request to redo this questionnaire.

Please check the relevant statements to you.

I am here for Gym Use / MembershipI am here for a Class/Club/EventI am here to see a Coach/Personal Trainer

I AGREE TO THE ABOVE TERMS & CONDITIONS!*

YesNo

Signature *