Fitness Dynamics PARQ Health Questionnaire

Pre-Activity Readiness Questionnaire (PARQ)

This PARQ is designed to help you to help yourself. Many benefits are associated with regular exercise and completion of the PARQ form is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose a problem or hazard. The PARQ has been designed to identify the small number of people for whom physical activity might be inappropriate, or for those who should seek medical advice concerning the type of activity most suitable for them. Common sense is your best guide for answering these questions. Note: this information will be kept confidential and only accessed by Fitness Dynamics.
Your Details
Name*

First NameLast Name
E-mail*
Date of Birth*

DayMonthYear
Gender
Contact Number (Mobile Number Preferred)*
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Next of Kin's Name*

First NameLast Name
Emergency Contact Number*
What are your short- and long-term goals in attending Fitness Dynamics classes?*
EG. Improved posture, weight loss, increased muscle tone, balanced hormones, less back pain, improved arthritis symptoms, flatter abdominals, decreased visceral fat (around the organs in the torso), stronger body, to feel more youthful, improved pelvic health, increased confidence, improved sleep, socialise more, meet new friends, improved sporting performance, improved mental health, to feel good etc.
Health Questions
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?*

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

YESNO
In the last month, have you had chest pain when you were not doing physical activity?*

YESNO
Do you lose your balance because of dizziness, or do you ever lose consciousness?*

YESNO
Do you have a bone or joint problem that could be made worse by a change in physical activity?*

YESNO
Do you suffer from high blood pressure?*

YESNO
Do you suffer from high blood pressure?

YESNO
Is your doctor currently prescribing medications (for example, water pills) for your blood pressure or heart condition?*

YESNO
Do you suffer from high cholesterol?

YESNO
Is there a history of coronary disease in your immediate family?

YESNO
If YES to any of the above, please specify details and explain how this affects your ability to exercise or achieve your fitness goals.*
If NO, please type N/A (Not Applicable)
Do you know of any other reason you should not do physical activity?*

YESNO
If YES, please specify?*
If NO, please type N/A (Not Applicable)
If you have answered YES to any of the above questions, then you are required to gain consent from your doctor before participating in the exercise sessions.

Talk to your Doctor either in person or by phone before you start becoming more physically active or join new fitness sessions. Tell your doctor what questions you answered yes to on this form.

You may still be able to do any activity you want as long as you start slowly and build up gradually or it may be that you need to restrict your activities to those which are safe for you.
Do you have any chronic illnesses or physical limitations such as asthma, diabetes, Hypermobility EDS, ME, fibromyalgia etc?*

YESNO
If YES, please specify and also explain how this affects your ability to exercise or achieve your fitness goals?*
If NO, please type N/A (Not Applicable)
Do you have any chronic illnesses or physical limitations?

YESNO
Have you had surgery in the last year?*

YESNO
If YES, please give specific details/date, the surgeon's recommendations and explain how/if this affects your ability to exercise or achieve your fitness goals?*
If NO, please type N/A (Not Applicable)
Do you take any medication (prescription or non-prescription) that affects your ability to exercise?

YESNO
If YES, please specify and explain how this medication affects your ability to exercise or achieve your fitness goals?
If NO, please type N/A (Not Applicable)
Do you have any pelvic health issues?*

YESNO
If YES, please specify?*
If NO, please type N/A (Not Applicable)
Do you know of any other reason you should not do physical activity?*
If NO, please type N/A (Not Applicable)
Are you pregnant or have had a baby within the last year?*

NOYES, I AM PREGNANTI GAVE BIRTH LESS THAN ONE YEAR AGO
If YES, please specify. How many weeks pregnant you are, or how old your baby is, or any other details?*
If NO, please type N/A (Not Applicable)
Do you have vision or hearing problems?*

YESNO
If YES, please specify?*
If NO, please type N/A (Not Applicable)
Delay becoming more active if:
- You have a temporary illness such as a cold or fever; it is best to wait until you feel
  better.
- You are pregnant - talk to your health care practitioner, your physician, a qualified exercise professional, before becoming more physically active.
- Your health changes - talk to your doctor or qualified exercise professional before continuing with any physical activity program.
- If you test positive for Covid please do not attend any community classes until your test is negative again.
If you have answered NO to all the above questions and you have reasonable assurance of your suitability for exercise, sign the participant declaration below.
- It is advised that you consult a qualified exercise professional to help you develop a safe and effective physical activity plan to meet your health needs.
- You are encouraged to start slowly and build up gradually - 20 to 60 minutes of low to moderate intensity exercise, 3-5 days per week including aerobic and muscle strengthening exercises.
- If you are over the age of 45 years and NOT accustomed to regular vigorous to maximal sort exercise, consult a qualified exercise professional before engaging in this intensity of exercise.
Lifestyle Questions

These help your instructor to support you on your wellness journey.
Do you smoke?

YESNO
Average per day?
Do you drink alcohol?

YESNOOther
Units per week?
Do you eat a diet of mainly vegetables, fruit and other plant-based foods?

YESNO
Do you have trouble falling asleep at night or sleeping soundly through the night?

YESNO
How many hours do you regularly sleep at night?
Describe your job/daily activities (select whichever is relevant to you?

SedentaryActivePhysically demanding
Does your job require travel?

YESNO
What is your current occupation, or previous occupation if you are retired?
This question relates to your long-term postural habits, spine health etc.
Do you make sure that you move around for at least 2 minutes in every hour of the day?

YESNO

On a scale of 1-10 how would you rate your stress level?

	1	2	3	4	5	6	7	8	9	10

1 is Very Low Stress, 10 is Very High Stress

Do you suffer/have suffered from eating disorders?

YESNO
Please describe your current activity levels *
(e.g. spin class x 2pw, gym x 3 pw, Pilates x 2 pw, walk the dog 2 miles a day, no exercise etc.)
If there is any other information you would like us to know please add it here...
Participant Declaration

All persons who have completed the PAR-Q+ please read and sign the declaration below. If you are less than the legal age required for consent or require the assent of a care provider, your parent/guardian or care provider must also sign this form.
“I confirm that where any medical condition, discomfort or injury which may be affected by physical activity applies or becomes applicable at any time when I am participating in a class, I am responsible for checking with my doctor to ensure I am able to participate in this activity.

I have been informed that if I answer yes to any of the health screening questions above, I should seek medical advice/approval before commencing classes with Fitness Dynamics. If I continue without such advice and therefore have not declared some health issues, I do so entirely at my own risk. I agree that any information, instruction, or advice obtained from Fitness Dynamics may NOT be used as a substitute for my doctor’s advice or treatment.

I confirm that I have read, fully understood and answered the questions honestly. If at any time I have questions, feel unsafe, or unwell I will immediately inform the instructor and discontinue further participation in the class.

Whilst I understand that every precaution will be taken while under instruction, I accept full responsibility for my actions and consider myself fit enough to take part in exercise. If participating in online exercise classes, I will ensure that I choose classes suitable for my health and fitness level and that the space I use to exercise in is large and clear enough to be safe to move around in without hazards.

I understand that instructors at Fitness Dynamics cannot be held responsible for any injuries or ill health of any kind arising from participation within classes and that my participation involves a risk of injury."

Please note that no liability is accepted for any loss of or damage to any articles which you may bring with you to classes or use at home. Equally, liability is not accepted for loss of or damage to motor vehicles or their contents and these are left at the owner’s risk.
Client's Signature:*

Clear
Please sign using your PC mouse, finger pad or touch screen. If you are unable to sign electronically then please type your full name in the boxes below.
Signed:

First NameLast Name
Witness Signature:*

Clear
Please sign using your PC mouse, finger pad or touch screen. If you are unable to sign electronically then please type your full name in the boxes below.
Signed:

First NameLast Name
Signature of Parent / Guardian / Care Provider: If not relevant please write N/A (Not Applicable)*

Clear
Please sign using your PC mouse, finger pad or touch screen. If you are unable to sign electronically then please type your full name in the boxes below.
Signed:

First NameLast Name
Date*

DayMonthYear
Date
May I send you class timetables, wellness information, relevant Fitness Dynamics news and advice via group email newsletters? I will never pass on your email address to anyone else and you can unsubscribe at any time.*

YESNO
I look forward to seeing you in a class or course soon. Please submit your form below. Thank you, Sam

You can save your form then re-visit to complete and submit it later, if required!
Which location/s do you/would you like to attend/participate?*
On a PC keyboard hold the Control Key (ctrl) down whilst clicking to choose more than one option
Should be Empty:

Pre-Activity Readiness Questionnaire (PARQ)

Lifestyle Questions

Participant Declaration

I look forward to seeing you in a class or course soon. Please submit your form below. Thank you, Sam