PAR-Q: Physical Activity Readiness Questionnaire
This form is designed to identify any health concerns that may need medical clearance before starting an exercise programme. Please answer all questions honestly
Full name
*
DOB
*
Email
*
example@example.com
Phone number
*
Emergency name & phone
*
Relationship
*
Health Questions
Please tick YES or NO for each:
Has your doctor ever said you have a heart condition or high blood pressure?
*
Yes
No
Do you ever feel chest pain when doing physical activity?
*
Yes
No
Have you had chest pain in the last month when not exercising?
*
Yes
No
Do you ever lose balance because of dizziness or lose consciousness?
*
Yes
No
Do you have any bone, joint, or muscle problems that could be made worse by activity?
*
Yes
No
Are you currently taking any prescribed medication for a health condition?
*
Yes
No
Are you pregnant or have you given birth in the last 6 months?
*
Yes
No
Do you know of any other reason why you should not take part in physical activity?
*
Yes
No
Other
If you answered YES to any question, or if you have any other medical conditions, past injuries, surgeries, or medications that may affect your ability to exercise, please give details below:
Terms & Conditions / Disclaimer
*
I confirm the information I have provided in this PAR-Q is correct and complete.I understand that I am responsible for monitoring my own health and wellbeing during exercise sessions.I will inform my trainer immediately if I experience any pain, dizziness, or discomfort while exercising.I understand that Coop Active is not liable for any injury or health issue that may arise if I have withheld information or failed to follow guidance.I have been advised to consult my doctor if I am unsure about my ability to participate in exercise safely.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: