Fitness Station ParQ
Please complete the Exercise Readiness Questionnaire below by answering 'yes' or 'no' to each question.If you answer 'yes' to any of the questions you will be asked to seek medical advice from your GP or Medical Advisor. We will still be able to process your membership today, however you will need to bring a letter of consent signed by your GP or Medical Advisor with you on your first visit. A member of our team will contact you to arrange your first visit to the club.
Personal Details
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: 00000 000 000.
Email
*
example@example.com
Address
*
Address Line 1
Address Line 2
City
County
Post Code
Medical Questionnaire
Has a doctor / medical professional ever diagnosed you with a heart condition and indicated you should restrict your physical activity?
*
No
Yes
When you perform physical activity, do you feel pain in your chest?
*
No
Yes
Do you ever faint or get dizzy and lose your balance?
*
No
Yes
Do you have an injury or orthopaedic condition (such as a back, hip, or knee problem) that may worsen due to a change in your physical activity?
*
No
Yes
Do you have high blood pressure or a heart condition in which a doctor / medical professional is currently prescribing a medication?
*
No
Yes
Are you pregnant?
*
No
Yes
Do you have insulin dependent diabetes?
*
No
Yes
Are you 69 years of age or older and not used to being very active?
*
No
Yes
Do you know of any other reason you should not exercise or increase your physical activity?
*
No
Yes
As far as I am aware I have answered all the above questions correctly. I hereby acknowledge that any false information could result in the cancellation of my membership.
Date
-
Month
-
Day
Year
Date
Submit
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