Physical Activity Readiness Questionnaire (PAR-Q)
If you are planning to take part in physical activity or an exercise class, start by answering the questions below. If you are between the ages of 16 and 69 the questions will tell you if you should talk with your doctor before you start. If you are over the age of 69 years of age and are not used to being very active, check with your doctor.
Name
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First Name
Last Name
DOB
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Month
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Day
Year
Date
Phone number
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Email address:
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Emergency contact name:
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First Name
Last Name
Emergency contact phone number:
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Has your doctor ever said that you have a heart condition and that you should only do physical activity that is recommended by a doctor?
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Yes
No
Do you feel pain in your chest when you do physical activity?
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Yes
No
In the past month have you had chest pain when you were not doing physical activity?
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Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
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Yes
No
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
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Yes
No
Is your doctor currently prescribing you drugs (for example water pills) for your blood pressure or heart condition?
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Yes
No
Are you pregnant, or have given birth in the last 6 months?
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Yes
No
Covid-19:
Have you had Covid-19?
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Yes
No
If you said yes to having Covid-19, have you experienced what you consider to be any signs of symptoms of Long Covid?
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Yes
No
I haven't had Covid-19
If you have had Covid-19 but answered No to the above question, have you noticed any changes to your normal level of energy, physical activity or exercise that has been altered or seems to be worsened since your exposure to the virus?
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Yes
No
I haven't had Covid-19
Do you know of any other reason why you should not do physical activity?
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Yes
No
If you answered yes to any of the pre-exercise questions please provide more details below, including how this may affect your participation during the session:
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. Tell your doctor about the questionnaire and which question(s) you answered yes to. You may be able to do any activity you want - as long as you begin slowly and build up gradually, or you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kind of activity that you wish to participate in, and follow his/her advice.
If you answered ‘no’ to all questions:
You can be reasonably sure that you can start to become more physically active and take part in a suitable exercise programme. Remember to start slowly and build up gradually. 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.
Please Note:
If your health changes so that subsequently you answer yes to any of the above questions, inform your fitness instructor immediately. Ask whether you should change your physical activity or exercise plan. Delay becoming more active if you feel unwell because of a temporary illness - wait until you are better.
Informed Consent
I fully understand that my participation in these sessions is completely voluntary and I may withdraw from the exercises at any time. I also confirm that I understand that exercise involves inherent but unlikely risk of injury and in extreme circumstances the possibility of death. I understand that should I feel light-headed, faint, dizzy, nauseated, or experience pain or discomfort, I am to stop the activity and inform my instructor. By signing below I confirm that I have read, understood and completed all of the pre-exercise medical questions to the best of my knowledge. Having answered YES to one or more questions above, I confirm that I have sought medical advice and my doctor has agreed that I may exercise. By signing below I release Olivia Sweeney from any liability with respect to any damage or injury which I may suffer whilst exercising.
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I understand and agree to all of the above
Participants privacy notice
All information provided on this form will be kept private and confidential. Please read this privacy policy and then check to indicate your consent to share this information with me. As your group exercise instructor, I am committed to protecting your privacy. This privacy policy sets out how I use and protect any information that you give me. As an attendee of my group exercise classes, I collect, store and use the personal data that you provide me. I do this so that I can effectively manage my classes and ensure that as a participant you are safe. I will use your data to inform me about any health considerations you have that I need to regard whilst delivering your class/es. If you have provided me with emergency contact details I will only use this information if required. I will not share the personal data enclosed in this PAR-Q. All digital data you provide to me is stored safely and securely on a password protected device. The only exceptions to this rule is if I carry paper copies of essential personal data that is required in case of emergencies to the class/es that you attend. In addition, in accordance with Government Covid-19 Guidelines at this current time, your name and contact information will be collected upon booking and shared with the venue for Track and Trace purposes. This information will be maintained by the venue for 21 days and then destroyed if not required. You may request details of personal data which I hold about you or withdraw your consent at anytime. You can contact me on oliviaisweeney@live.co.uk or 0754531056.
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I consent
Print Name
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TODAY'S Date
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Signature
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Clear
Submit
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