MK27Fitness PARQ

Your Details

Full Name*

First NameLast Name

Date of Birth*

DayMonthYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

Phone Number*

Format: 00000000000.

Before you begin exercising your instructor needs to know some information about you to ensure the exercises are safe and effective. If you are between 15-69 years of age this PAR Q checklist will assist you in making a decision about your state of health before you change or increase your physical activity behaviour. If you are over 69 years of age and not already participating in regular exercise it is advisable to check with your doctor before you begin.

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*

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 because of dizziness or do you ever lose consciousness?*

YESNO

Do you have a bone or joint problem (e.g., back, knee or hip) that could be made worse by a change in your physical activity?*

YESNO

Is your doctor currently prescribing any medication for your blood pressure or heart condition?*

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?

Do you know of any other reason why you should not participate in physical activity? If yes, please explain.*

YESNO

If YES please specify:

If you answered:

YES to one or more of the questions above you should consult your doctor to gain consent before participating in physical activity.

NO to all the questions above it is considered reasonably safe for you to participate in regular physical activity. It is recommended that you start slowly – 20-30 minutes of low to moderate exercise, 3-5 times per week – and gradually build up from your current ability level.

It is advisable to consult with a qualified fitness professional to help you develop a safe and effective physical activity plan to meet your fitness goals and health needs.

I have read and understood the questions above and any questions I had have been answered to my satisfaction.

I understand that I am voluntarily engaging in a level of exercise appropriate for my ability and that my participation involves a risk of injury.

Do you smoke?

YESNO

Average per day?

Do you drink alcohol?

YESNO

Units per week?

How many hours do you regularly sleep at night?

Describe your job (select whichever is relevant to you?

SedentaryActivePhysically demanding

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 (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

Full Name*

First NameLast Name

Phone Number*

Format: 00000000000.

Relationship*

I am happy for MK27Fitness to contact me by: (please tick as appropriate)*

EmailPostText/ Phone

I am happy for MK27Fitness to use my testimonial for marketing purposes:*

YesNo

I am happy for MK27Fitness to use my photo for marketing purposes:*

YesNo

I agree to MK27Fitness to send me updates on MK27Fitness products and promotions. I agree to them contacting me using the details provided and understand that these details will be added to the MK27Fitness database.*

YesNo

I do not want MK27Fitness to send me any marketing materials. I understand that they will need to store my details for payments and for emergency contact details.*

Yes

MK27Fitness Exercise Form

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

If you answered:

Lifestyle Questions

Emergency Contact