Physical Activity Readiness Questionnaire

Physical Activity Readiness Questionnaire
Personal Details
Name

First NameLast Name
Date of Birth

MonthDayYear
Email Address
example@example.com
Emergency Contact
Emergency Telephone Number
Regular physical activity has many health benefits, however, some people should check with their doctor before they start. When planning to undertake physical activity, you should start by answering the questions below. If you are in any doubt, consult with your G.P. before commencing exercise.

Please read the questions carefully and answer them honestly by clicking YES or NO.
Health Screening Questionnaire
1. Has your doctor ever said that 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 that could be made worse by a change in your physical activity level?

YesNo
6. Have you ever had any problems with your back?

YesNo
7. Is your doctor currently prescribing any medication for your blood pressure or a heart condition?

YesNo
8. Is there any family history of heart disease, stroke, raised cholesterol or high blood pressure?

YesNo
9. Do you suffer from diabetes/epilepsy/asthma?

YesNo
10. Are you pregnant, or have you given birth in the last six weeks?

YesNo
11. Do you have, or have you had any illnesses recently?

YesNo
12. Have you recently had surgery?

YesNo
13. Do you know of any other reason why you should not do physical activity?

YesNo
If you have answered ‘yes’ to any of the questions above, please can you give brief details below. We may require you to obtain written consent from your G.P. before agreeing to allow you to undertake any physical exercise in the gym.
14. What are your aims for exercising? Please give detail:
15. Present and past activity levels, how often and what type? Please give detail:
Client Declaration
I have read and fully understood the Exercise Readiness Questionnaire. I confirm that, to the best of my knowledge, the answers are correct and accurate. I know of no reason why I should not participate in an exercise workout. I understand that I would be using the Health & Fitness facilities entirely at my own risk and waive any legal recourse for damages to myself or property arising from my participation.

I understand that I should not exercise if I feel unwell and that if my health changes I should inform my instructor.
Signed:

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Physical Activity Readiness Questionnaire

Personal Details

Health Screening Questionnaire

Client Declaration