CLASS PAR-Q

Full Name & Phone Number

Full NamePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Emergency Contact Details

Name & RelationshipPhone Number

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

Have you ever felt pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Have you ever suffered from unusual shortness of breath at rest or with mild exertion?

Do you often feel faint, have spells of severe dizziness or have lost consciousness?

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?

Are you pregnant or have you recently given birth?

Is your doctor currently prescribing you medication for blood pressure, heart problem, diabetes, or any other serious medical condition?

Do you know of any other reason why you should not participate in physical activity?

If you have ticked or answered yes to any of the above questions, please provide further details

If you answered 'yes' to one or more questions, if you have not recently done so, please consult with your doctor to gain consent before participating in an exercise class, and do not ignore any advice given. There exists the possibility of certain dangers when exercising. They include abnormal blood pressure, fainting, irregular / fast / slow heart rhythm, and in rare instances, heart attack, stroke, or death. Whilst every care will be taken, it is impossible to predict the body's exact response to exercise. Every effort will be made to minimise these risks by evaluation of the information provided on this form, and by observations during exercising. Please confirm that you have read and understood the above, that you have accurately completed this questionnaire, and that you have followed any advice provided by your doctor. Please confirm that you are voluntarily engaging in an acceptable level of exercise with Kathie McKay, and that your participation could involve a level of risk. Select 'Yes' if you agree

Please Retype Your Name

Full Name

Date

NB. Should your condition change from a YES to a NO on any of the questions above, please check with your GP to make sure it's ok for you to exercise. Always keep your instructor informed, and complete this form again.

This information is confidential and will be used for the purpose of ensuring the exercise sessions are suitable for you, and in the case of medical emergency. Your may be contacted from time to time by Kathie McKay with information or updates regarding the class/classes.

Physical Activity Readiness Questionnaire (PAR-Q)