Par Q Fitness Questionnaire
Complete this form to assess your fitness for participation and ensure safety.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: 00000000000.
Email Address
example@example.com
Today's Date
*
-
Day
-
Month
Year
Date
Please answer the following questions by selecting Yes or No.
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing medication for your blood pressure or heart condition?
*
Yes
No
Do you know of any other reason why you should not do physical activity?
*
Yes
No
If you answered 'Yes' to any of the above questions, please provide more details below and speak to the instructor before the class:
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: 00000000000.
Submit
Should be Empty: