PARQ - Medical history form

PARQ - Medical History

Please take a few minutes to answer the questions below. Any information disclosed in this form will be treated as confidential. If you have any questions please feel free to contact me directly on 07581343557.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Name and phone number of someone to contact in an emergency.
Name and contact details for your GP
Check the conditions that apply to you or to any members of your immediate relatives:

AsthmaCardiac disease or heart conditionBone or Joint conditions e.g. arthritisDiabetesHypertensionEpilepsyMuscular e.g. injury or weaknessBack pain or injuryOther
If you have checked any of the conditions above please give further details
Are you currently exercising?

YesNo
Do you or have you ever experienced any of the following while exercising?

Fainting or light headednessShortness of breathChest pain or heart palpitationsleg painOther
If you have checked any of the symptoms above please give details here.
Are you, or is there any possibility you may be pregnant?

YesNo
Are you currently taking any medication?

YesNo
Please give details of any medication here
Do you have any medication allergies?

YesNoNot Sure
Do you use or do you have history of using tobacco?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
Do you know of any other reason why you should not participate in a program of physical activity? Yes/No. If yes please give details below
Assumption of risk.

I hereby state that I have read, understood and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, strength/muscle conditioning exercises and stretching. I realise that my participation in these activities may involve a risk of injury.
Signature

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Date

MonthDayYear
Date
Should be Empty:

PARQ - Medical History