Be Active with Alison PAR-Q Form

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Your Full Name* This field is required.
First Name
Last Name
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Participants Phone Number
Area Code
Phone Number
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Instructor / Coach* This field is required.
Alison
Lane
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Next of Kin Name
First Name
Last Name
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Next of Kin Phone Number
Area Code
Phone Number
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Please read the following questions carefully and check (X) next to the appropriate answers. Answer all questions honestly and to the best of your ability.

If you are planning to take part in physical activity or an exercise class, start by answering the questions below. If you are between the ages of 15 & 69 the questionnaire will tell you if you should check with your doctor before you start. If you are 69 years of age, and you are not used to being very active, check with your doctor.

All information will be treated confidentially.
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YES/ NO* This field is required.
Yes
No
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
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Do you ever feel pain in your chest when you do physical activity?
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Have you ever, especially In the past month, had chest pain when you were not doing physical activity?
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Do you lose your balance because of dizziness or do you ever lose consciousness?
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Do you ever feel faint or have spells of dizziness?
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Do you have a diagnosed illness that could be made worse by physical activity?
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Is your doctor currently prescribing medication for your blood pressure or heart condition?
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Have you ever been told that you have high blood pressure?
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Are you pregnant now or have given birth within the last 6 months?
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Have you had a recent surgery?
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Are you currently on any medications, either prescription or non-prescription, on a regular basis?
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Do you have a joint problem that could be made worse by physical exercise?
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Is there any other reason why you should not participate in physical activity?
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Row 12, Column 1
Has your doctor ever said that you have a heart condition (had a stroke, heart attack, or heart surgery) and/ or that you should only do physical activity recommended by a doctor?
Do you ever feel pain in your chest when you do physical activity?
Have you ever, especially In the past month, had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you ever feel faint or have spells of dizziness?
Do you have a diagnosed illness that could be made worse by physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Have you ever been told that you have high blood pressure?
Are you pregnant now or have given birth within the last 6 months?
Have you had a recent surgery?
Are you currently on any medications, either prescription or non-prescription, on a regular basis?
Do you have a joint problem that could be made worse by physical exercise?
Is there any other reason why you should not participate in physical activity?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
Yes
Row 7, Column 0
No
Row 7, Column 1
Yes
Row 8, Column 0
No
Row 8, Column 1
Yes
Row 9, Column 0
No
Row 9, Column 1
Yes
Row 10, Column 0
No
Row 10, Column 1
Yes
Row 11, Column 0
No
Row 11, Column 1
Yes
Row 12, Column 0
No
Row 12, Column 1
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If you have answered 'Yes' to any of the previous questions, please elaborate below:
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Date
Date
Day
Month
Year
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Signature
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If you have answered YES to one or more of the previous questions;

Talk to your doctor by phone or in person before you start becoming more physically active and before you have a fitness assessment. Tell your doctor about the questionnaire and which questions you answered YES to. You may be able to take part in any activity you want as long as you begin slowly and build up gradually or you may need to restrict your activities to ones which are safer you. Talk with your doctor about the kind of activity you wish to participate in and follow their advice.

If you have answered NO to all questions;

You can be reasonably sure that you can start to become more physically active and take part in a suitable exercise programme. Remember, begin slowly and build up gradually.

Fitness Participation Agreement

I have answered the questions to the best of my ability and affirm that my physical condition is good and I have no known conditions that would prevent me from participation. I acknowledge that participation is at my own pace and comfort level and that I may discontinue my participation in the sessions at any time. Furthermore, I agree to self-determine my exertion through good judgement and to discontinue any activity that exceeds my personal limitations. I understand that by signing this agreement that I hereby waive and release Be Active with Alison, in any way from liabilities or demands as a result of injury, loss, or adverse health conditions as a result of my participation. I affirm that I have read and understand this document and I wish to participate in fitness activities.
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Informed Consent Form

The purpose of an exercise programme is to help you achieve health and fitness goals.

You will be set a programme based upon your present activity/exercise levels and your stated goals. You will experience some feelings of exertion during each activity session and may become hot and uncomfortable at times. If you plan includes certain types of cardiovascular exercise you can expect your breathing to become more rapid and your heart rate to increase. As your fitness improves, your goals may lead you to participate in more vigorous levels of activity but these should remain within your capabilities.

All activities will be explained and demonstrated to you but you should feel free to ask any questions you may have. Any exercise programme carries with it an element of risk. The sessions are designed to minimise risk, yet at the same time, provide an effective exercise/activity programme. Please inform the instructor if there is any reason why you should not participate in an activity. i.e. if you have an illness or an injury which might be aggravated by exercise.

If, at any time, you feel feel undue pain or excessive discomfort stop the activity immediately and inform the instructor of your symptoms. You are free to withdraw from any activity at any time you wish.

I agree to take part in the programme described to me by my instructor. The nature, purpose, risks and benefits have been explained to me and I understand what is required of me and that I may withdraw at any time.
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Date
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Signature of Participant:* This field is required.
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Do you consent to being photographed or video’d for the purposes of my social media, website and other advertising?
Please Select
Please Select
Yes
No
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WhatsApp Announcement Only GroupWould you like to be added to the class WhatsApp announcement only group. Only admins can post. Participants cannot reply.
Please Select
Please Select
Yes
No
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Signature
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Date
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