ParQ_Screening

Regular physical activity can be fun and great for your health, increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start increasing the amount they exercise or if they begin a new activity. If you are planning to become more physically active than you are now, start by answering the 8 questions below.

The PAR-Q will tell you if you should check with your doctor before you start.

Common sense is your best guide when answering these questions. Please read the questions carefully and answer each one honestly by ticking the appropriate box.

Full Name

First NameLast Name

Date of Birth

DayMonthYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Gender

Phone Number

Email Address

Occupation

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

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not engaged in physical activity?

Do you lose your balance due to dizziness or ever lose consciousness?

Do you have a bone or joint problem which could be made worse by a change in your physical activity?

Are you presently taking any medication for blood pressure or a heart condition?

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

If you answered YES to one or more of the above questions, talk with your doctor and coach BEFORE you start becoming more physically active. Tell your doctor about the PAR-Q and which questions you answered YES.

If you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better. If you are showing symptoms do not exercise or attend sessions. If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.

Safety Agreement

I acknowledge that there are risks and dangers inherent in physical exercise and declare that I know of no reason why I should not take part in exercise. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction.

I understand that any exercise taken is at my own risk and I agree to waive any legal recourse (other than for negligence) for any damages to myself arising from my participation. I also agree to follow any verbal instructions given by the fitness staff and to observe any written notices regarding safety whilst visiting the facility.

Date

Signature

Email

example@example.com