Health Questionnaire Form PARQ

Health Questionnaire (PAR Q)

This questionnaire is designed to help you help yourself. Many health benefits are associated with regular exercise and the completion of this questionnaire is a sensible first step to take if you are planning to increase the amount of physical activity in your life.
Full name*

First NameLast Name
Birthday*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
Mobile Phone Number
Emergency contact*

First NameLast Name
Mobile Phone Number
Clients informations - Health questionnaire (Par-Q)
Common sense is your best guide when you answer this questionnaire. Please read the questions carefully and answer each one honestly: check YES or NO.

Par-Q*

	Yes	No
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel fain in your chest when you do physical activity?
n the past month, have you had chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have bone or joint problem (for example, back, knee, or hip) that could be worsen by a change in your physical activity?
Is your doctor currently prescribing drugs (for example water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
Asthma
Do you participate in exercise regularly
Have you had Covid
If yes, are you suffering with long covid symptoms (fatigue, short of breath)

Client informations - Liability waiver
A GRADUATED EXERCISE PROGRAMME

A gradual increase in regular exercise promotes fitness and improves overall health while minimising or eliminating discomfort. Postpone entry into the programme if you feel unwell or have a temporary illness.

For most people physical activity should not pose a problem or hazard.
Initials*
Data Protection GDPR (Act 2018)
Data Protection (GDPR) Act 2018                    Please circle your answers

I agree for Jacqui Smith Personal Trainer to hold my details above for 1 year, where it will be updated or destroyed (as applicable)

I am happy for Jacqui Smith Personal Trainer and her team to take photographs and use on her social media facebook & Instagram sites, newsletters and website

I am happy for Jacqui Smith use my email to keep me informed of classes, diet & nutrition information and that I can delete myself at any time.

More information on our Data Protection policy can be requested at theteam@jacqui-smith.net

Please email if you wish for no photographs, you can delete yourself from the the emails I send out weekly at any time or email theteam@jacqui-smith.net
Initials or AGREE or NOT AGREE about GDPR*
Client informations - Signature
Signature

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Date

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