Physical Activity Readiness Questionnaire (PAR-Q)

Physical Activity Readiness Questionnaire (PAR-Q)

THIS FORM IS CONFIDENTIAL
Name*

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Date of Birth*

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Health Questionnaire (PAR-Q)
This PAR-Q is designed to help you to help yourself. Many benefits are associated with regular exercise, and completion of the PAR-Q form is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people, physical activity should not pose a problem or hazard. The PAR-Q has been designed to identify the small number of people for whom physical activity might be inappropriate or for those who should seek medical advice concerning the type of activity most suitable for them. Common sense is your best guide for answering these questions.

PAR-Q*

Rows	YES	NO
Has your doctor ever said that you have a heart condition or hypertension and/or recommended supervised activity?
Do you feel 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?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing any medication or treatments?
Do you suffer with lower back pain?
Do you have asthma?
Do you have epilepsy?
Do you have coronary heart disease?
Do you have diabetes?
Are you pregnant or given birth/miscarried in the last 6 weeks?
Do you know of any other reason why you should not do physical activity?

If you have answered YES to any of the above questions, you should seek medical advice/medical clearance from your GP/healthcare professional before participating in the group exercise to music session. If you have answered NO to all of the above questions and you have reasonable assurance of your suitability for a group exercise to music session – which will include: a warm up, a main component (consisting of cardiovascular exercise and muscular endurance/conditioning) and cool down with stretches. You are advised to postpone entry into the programme if you feel unwell or have a temporary illness. You must inform your instructor of any changes to your health status, whilst engaged in your exercise sessions.
If you're on any medications, please list them and state what they're for*
If you have any current or previous injuries, please list them*
Client Confirmation - Signature

Please read the below statement and sign to show you have understood the risks to exercise and are fit to take part
Please note that no liability is accepted for any loss of or damage to any articles, which you may bring with you to classes. Equally, liability is not accepted for loss of or damage to motor vehicles or their contents and these are left at the owner’s risk.

“I confirm that where any medical condition, discomfort or injury which may be affected by physical activity applies or becomes applicable at any time when I am participating in a class, I am responsible for checking with my doctor to ensure I am able to participate in this activity.”
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Physical Activity Readiness Questionnaire (PAR-Q)

Health Questionnaire (PAR-Q)

Client Confirmation - Signature