PAR-Q

The form below is compulsory for all clients of Emily Ingham Fitness Ltd.

The questionnaire below will tell you whether it is necessary for you to seek medical advice before becoming more physically active. If you answer yes to any of the below questions, please seek medical advice before exercising. If you answer no to all of the below questions, you are cleared for physical activity.

First name

Last name

1) Has your doctor ever said that you have a heart condition or high blood pressure?

Yes

No

2) Do you feel pain in your chest at rest, during your daily activities or when you do physical activity?

Yes

No

3) Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

Yes

No

4) Have you been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?

Yes

No

5) Are you currently taking any prescribed medications for a chronic medical condition?

Yes

No

6) Do you have any (or have had in the past) a bone, joint or soft tissue (muscle, ligament or tendon) problem that could be made worse by becoming more physically active?

7) Has your doctor ever said that you should only do medically supervised physical activity?

Yes

No

8) Females only - Are you pregnant or have you had a baby in the last 6 months?

Yes

No

If you answered yes to any above questions, please give more details about conditions here.

If you answered yes to taking prescribed medication, please give more details here.

If there is anything not covered above, please give more information here.

I, the undersigned, have read, understood to my full satisfaction and completed this questionnaire. I acknowledge that this physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if my condition changes. I also acknowledge that Emily Ingham Fitness Ltd may retain a copy of this form for its records. In these instances, it will maintain the confidentiality of the same, complying with applicable law.

Signature

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Based on the information you have given, an exercise programme will be designed for you. This will involve activities to progressively challenge your cardiorespiratory and musculoskeletal systems (heart, lungs, muscles and joints). You may feel tired during and following the exercise sessions, and occassionally experience some soreness, but this is not unusual and you will be monitored closely. Please consult your trainer if you have any concerns.

I hereby state that I have read, understood and answered honestly the questions on the PAR-Q. I am willing to participate in the physical activities that may include aerobic exercise, resistance exercise and flexibility exercises. I realise that in participating in these activities I may be at risk of injury and even the possibility of death. I hereby confirm that I am participating voluntarily and understand that I can withdraw at any time.

Signature

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