PARQ

Pre-Activity Readiness Questionnaire (PAR-Q)
The information contained within this form will help us agree whether you are safe to take part in Zumba classes or not. If there is any doubt regarding your fitness to train you should consult your GP. Note: this information will be kept confidentially and only accessed by Samantha Lawrence
Your Details
Full Name*

First NameLast Name
E-mail*
Date of Birth*

DayMonthYear
Phone Number*
Format: 00000000000.
Health Questions
Has your Doctor ever said you have a heart condition?*

YESNO
Do you have pains in your chest whilst performing physical activity?*

YESNO
Have you had chest pain while not doing physical activity?*

YESNO
Do you lose your balance due to dizziness or ever lose consciousness?*

YESNO
Do you suffer from high or low blood pressure?*

YESNO
Do you suffer from high cholesterol?*

YESNO
Have you had surgery recently?*

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

YESNO
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?*

YESNO
Do you have any chronic illnesses or physical limitations such as asthma or diabetes and whether it affects your ability to exercise?*

YESNO
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?*

YESNO
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?*

YESNO
If YES please specify and also explain how this medication affects your ability to exercise or achieve your fitness goals?
Are you pregnant or have you had a baby within the last 6 weeks?

YesNo
If yes, is there any reason why you should modify your movements?

Yes - I’m having a complicated pregnancyYes - I had a c section or assisted deliveryYes - I have ab separationNo - my pregnancy and/or delivery was straight forward
Do you know of any other factor which may affect your ability to participate in physical activity?*

YESNO
If YES please specify:
If you have answered YES to any of the questions above we will need to make a reasoned judgement with you as to whether consent is required from your Doctor prior to commencing any program of activity with Zumba with Samantha.
Lifestyle Questions
Do you smoke?*

YESNO
Average per day?*
Describe your job (select whichever is relevant to you?*

SedentaryActivePhysically demanding
Does your job require travel?*

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

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 and/or taking a fitness appraisal. 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.
Emergency Contact
Full Name*

First NameLast Name
Phone Number*
Format: 00000000000.
Relationship*
Should be Empty:

Pre-Activity Readiness Questionnaire (PAR-Q)

Lifestyle Questions

If you answered YES to one or more questions

Emergency Contact