Clubhouse Jesmond

Name*

First NameLast Name

Has your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or might be made worse with exercise?*

YesNo

Do you have high blood pressure?*

YesNo

Do you have low blood pressure?*

YesNo

Do you have diabetes mellitus or any other metabolic disease?*

YesNo

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

YesNo

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

YesNo

Is your doctor currently prescribing you drugs or medication?*

YesNo

Is there any history of coronary heart disease in your family?*

YesNo

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

YesNo

Do you currently smoke?*

YesNo

Are you, or is there any possibility that you might be pregnant?*

YesNo

Do you know of any reason why you should not participate in a program of physical activity?*

YesNo

If you answered 'yes' to one or more questions:

If you have not recently done so, consult with your doctor by telephone or in person before increasing your physical activity and/or taking a fitness appraisal. Tell your doctor what questions you answered 'yes'' to on the PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for:

- Unrestricted physical activity starting off easily and progressiong gradually and,

- Restricted or supervised activity to meet your specific needs, at least on an initial basis

No to all questions:

If you answered your PAR-Q accurately, you have reasonable assurance of your present suitability to take part in physical gym activity.

Assumption of risk:

I hereby state that I have read, understood and answered honestly the questions of the PAR-Q. I also state I wish to participate in activites that may include aerobic exercise, resistance training and stretching. I realise that my participation in these activites involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise.

Date*

Date

Signature*

JMARFITNESS