Physical Activity Readiness Questionnaire (PAR-Q)
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Emergency Contact Information
Name
First Name
Last Name
Phone Number
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Area Code
Phone Number
Health Questions
Has your doctor ever said you have a heart condition, or have you ever suffered from chest pain while exercising?
*
Yes
No
Do you ever experience chest pain when not performing physical activity?
*
Yes
No
Do you lose balance because of dizziness, or have you ever lost consciousness?
*
Yes
No
Do you have any bone, joint, or muscle problems that could be made worse by physical activity?
*
Yes
No
Are you currently taking any prescribed medications for blood pressure, heart conditions, diabetes, or any other health issues?
*
Yes
No
Do you know of any other reason why you should not take part in physical activity?
*
Yes
No
Guidance
If you answered YES to one or more questions: Please consult your GP or healthcare provider before starting physical activity. If you answered NO to all questions: You can be reasonably sure it is safe to participate
Declaration
I confirm that the above information is correct to the best of my knowledge. I will inform my trainer of any changes to my health status. I take full responsibility for my participation in exercise and understand that Struthers Fitness is not liable for any injury, illness, or health complications that may occur.
Client Signature
*
Sign Date
*
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Month
-
Day
Year
Date
Trainer Signature
Sign Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: