PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Rows	Yes	No
Do you have a bone or joint problem such as arthritis?
To your knowledge, do you have high blood pressure?
To your knowledge, do you have low blood pressure?
Do you have Diabetes mellitus or any other metabolic disorder?
Has your doctor ever said that you have raised cholesterol (serum level above 6.2mmol/L)?
Do you have or ever suffered a heart condition?
Have you ever felt pain in your chest when you do physical exercise?
Is your doctor currently prescribing you drugs or medication?
Have you ever suffered from shortness of breath at rest or with mild exercise?
Is there any history of Coronary Heart Disease within your family?
Do you ever feel faint, have spells of dizziness or have ever lost consciousness?
Are you, or is there any possibility that you might be pregnant?
Do you know of any other reason why you should not participate in a programme?
Do you suffer from epilepsy?
Do you have any blood bore diseases? e.g. hepatitis, HIV etc
Does the number 12 come after the number 11?
Do you have any skin conditions? e.g. dermatitis etc
Do you have Asthma? (if 'YES', give your inhaler labelled with your name to the medics before your bout.

If you have answered 'YES' to any of the above please give details:

If you answered 'YES' to one or more questions: If you have not already done so, consult with your doctor by telephone or in person before increasing your physical activity. Inform your doctor of the questions that you answered 'yes' to on the PAR-Q or present your PAR-Q copy. After medical evaluation, seek advice from your doctor as to your suitability for the activity you wish to undertake.

Assumption of Risk
I hereby state that I have read, understood the information above and answered honestly to the questions. I also state that I wish to participate in activities, which include; aerobic exercise, resistance exercise, flexibility exercise and boxing. I realise that my participation in these activities involve the risk of injury. I hereby confirm that I am voluntarily engaging in exercise, which has been recommended to me.

if you answered 'NO' to all questions honestly and accurately, you have reasonable assurance of your present suitability for unrestricted physical activity.

Signing this agreement means you understand the above, agree to take part in the event & are aware of any risks that could occur.

Clients Signature:

B.P.

Clients Name:

PULSE

PERL

Date:

Date

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

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