Thanet Fitness Parq

Pre-Activity Readiness Questionnaire (PAR-Q)
The information contained within this form will help us agree whether you are safe to train or not. If there is any doubt regarding your fitness to train you should consult your GP.

Note: this information will be kept confidentially and only accessed by Natalie Lowe
Your Details
Full Name*

First NameLast Name
E-mail*
Date of Birth*

DayMonthYear
Phone Number*
Health Questions
Has your Doctor ever said you have a heart condition?*

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 due to dizziness or ever lose consciousness?*

YESNO
Do you suffer from high or low blood pressure?*

YESNO
Have you had surgery recently?*

YESNO
Is there a history of coronary disease in your immediate family?*

YESNO
Do you have any chronic illnesses or physical limitations?*

YESNO
Do you have any injuries, bone/joint or orthopedic problems (such as back, shoulder, knee etc) that could be made worse by physical activity?*

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 factor which may affect your ability to participate in physical activity?*

YESNO
If YES please specify:
Emergency Contact
Full Name*

First NameLast Name
Phone Number*
Relationship*
I confirm that I have read, understood, and accurately completed this questionnaire. I acknowledge that I am voluntarily participating in an exercise program provided by my trainer, Natalie Lowe, and understand that participation may involve a risk of injury. I have informed Natalie Lowe of any pre-existing injuries or underlying conditions and will continue to do so if this information changes at any time.
Date

MonthDayYear
Date
Signature*

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Date

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Date
Signature*

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Pre-Activity Readiness Questionnaire (PAR-Q)

Emergency Contact