ParQ_Screening

Par Q

Physical Activity Readiness Questionnaire
Full Name*

First NameLast Name
Date of Birth

DayMonthYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex
Phone Number*
Email Address*
Occupation
Heart Condition?

YesNo
Chest Pains?

YesNo
Low / High Blood Pressure?

YesNo
Dizziness During / After Physical Exercise?

YesNo
Pre / Post Natal?

YesNo
Medication?

YesNo
Joint Bone Issues?

YesNo
Currently Injured?

YesNo
Currently Ill?

YesNo
Mental Health Issues?

YesNo
Do you know any reason you should not exercise or do physical activity?

YesNo
If you answered yes to any of the above questions, talk with your Doctor BEFORE you begin training. Tell the doctor of your intention to exercise and which questions you answered ‘yes’ to. If at any stage your health changes , resulting in a ‘yes’ answer to the above questions please seek guidance from a GP.
Problem Areas
Goals
Exercise History
Dietary Issues
Smoker
Alcohol Intake
Hours Sleep Per Day
Weight (kg)
Height (cm)
Activity Level
Do you give GLOW FIT Health and Well -being permission to be able to use your image for promotional & advertisement purposes?

YesMaybeNo
- I have read, understood and completed this questionnaire and consider myself fit for exercise.

- Any questions that I have answered are to my full satisfaction

- I understand that I am exercising under my own volition

-I agree to follow the exact programme give to me by the coach

- I will Advise the Coach of any health problems experienced while taken part in the programme

-I take part in any recommended programme entirely at my own risk and waive any legal recourse for damage to myself or property arising from my participation

- I understand and agree to these conditions

- Please note flashing lights are used in dance class if you have sensitivity to lights Please be aware you come to class at your own risk.

-Any Payments made are non- refundable.

-Transfer can be made with 24 hrs notice before Class is due to Start
Date*
Signature*
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