Sarah Mariani PT - Physical Activity Readiness Questionnaire

Pre-Activity Readiness Questionnaire (PAR-Q)
The information contained within this form will help determine whether you are safe to train. The absolute priority at Sarah Mariani PT is to keep you safe whether you are training in person or virtually. If there is any doubt regarding your fitness to train you should consult your GP.
Your Details
Full Name *

First Name Last Name
E-mail *
Date of Birth *

Day Month Year
Phone Number *
Health Questions
Has your Doctor ever said you have a heart condition? *

YES NO
Do you have pains in your chest whilst performing physical activity? *

YES NO
Have you had chest pain while not doing physical activity? *

YES NO
Do you ever lose your balance due to dizziness or ever lose consciousness? *

YES NO
Do you suffer from high or low blood pressure? *

YES NO
Do you suffer from high cholesterol? *

YES NO
Have you had surgery recently? *

YES NO
Is there a history of coronary disease in your immediate family? *

YES NO
If YES to any of the above please specify and also explain how this affects your ability to exercise or achieve your fitness goals?:
Do you have any chronic illnesses or physical limitations? *

YES NO
Do you suffer with asthma or diabetes? *

YES NO
If YES please specify and also explain how this affects your ability to exercise or achieve your fitness goals?:
Do you have any injuries, bone/joint or orthopedic problems (such as back, shoulder, knee etc) that affect your ability to exercise? *

YES NO
If YES please specify and also explain how this affects your ability to exercise or achieve your fitness goals?:
Do you take any medication (prescription or non-prescription) that affects your ability to exercise? *

YES NO
If YES please specify:
Do you know of any other factor which may affect your ability to participate in physical activity? *

YES NO
If YES please specify:
If you have answered YES to any of the questions above you will need to seek consent from your Doctor prior to commencing any program of activity with Sarah Mariani PT.
Lifestyle Questions
Do you smoke? *

YES NO
Average per day? *
Do you drink alcohol? *

YES NO
Units per week? *
How many hours do you regularly sleep at night? *
Describe your job (select whichever is relevant to you? *

Sedentary Active Physically demanding
Does your job require travel? *

YES NO

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? *

YES NO
Please describe your current activity levels (eg spin class x 2pw, gym x 3 pw, pilates etc)
If there is any other information you would like us to know please add it here
If you answered YES to one or more questions
Talk to your Doctor either in person or by phone before you start becoming more physically active. Communicate to your Doctor what questions you answered yes to on this form.

You may be required to start slowly and build up gradually or it may be that you need to restrict your activities to those which are safe for you.
Emergency Contact
Full Name *

First Name Last Name
Phone Number *
Relationship *
Should be Empty:

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Pre-Activity Readiness Questionnaire (PAR-Q)

Lifestyle Questions

If you answered YES to one or more questions

Emergency Contact