PAR Q FORM

1

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

YESNO

2

Do you feel pain in your chest when you do physical activity?

YESNO

3

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

YESNO

4

Do you lose balance because of dizziness or do you ever lose consciousness?

YESNO

5

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

6

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

YESNO

7

Do you know of any other reason why you should not take part in a physical activity? If YES please specify on the next page

YESNO

8

Specify as to why you can not take part in physical activities

9

If you answered YES to one or more questions:

You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

If you answered NO to one or more questions:

It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.

10

Terms and Conditions* This field is required.I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involved a risk of injury.