Gym Pal Expression of Interest Form

If you are between the ages of 15 and 69, this PAR-Q form will inform you if you should check with your doctor before you significantly change your physical activity patterns. If you are over the age of 69 and are not used to being very active, check with your doctor.

Please read each question carefully and answer honestly by ticking either YES or NO.

Full Name*

First NameLast Name

E-mail

example@example.com

Mobile number*

PAR-Q Questions*

	YES	NO
1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
2. Do you feel pain in your chest at rest, during your daily activities, or when you do physical activity?
3. In the past month, have you had a chest pain when you are not doing physical activity?
4. Do you lose balance because of dizziness or do you ever lose consciousness?
5. Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)? If YES, please list conditions below.
6. Is your doctor currently proscribing medication for your blood pressure or heart condition?
7. Do you know of any other reason why you should not take part in physical activity? If YES, please comment below.

If you answered YES to question five, please list below:

If you answered YES to question seven, please list reasons:

If you answer 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 answer NO to all questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current level. A fitness appraisal can help determine your ability levels.

Please tick the following:*

I have read, understood and accurately completed this PAR-Q. I can confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.

NOTE: This PAR-Q becomes invalid if your condition changes so that you would answer YES to any of the above.

PAR-Q Physical Activity Readiness Form