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Physical Activity Readiness Questionnaire (PAR-Q)

Name *

First

Last

Mobile

Email *

Date of Birth

Home Address

Name & Tel No of next of kin:

Any Medical Conditions, pregnancies or injuries ?

Current medications (if any):

Have you experienced any heart problems?

Have either of your parents had a heart attack under the age of 60:

Females - Advise of pregnancy or post-natal within 1 year of birth:

Do you consider yourself fit & well enough to partake in an exercise programme ? If any doubt please contact your GP:

ALL EXERCISE CARRIES A RISK OF INJURY. PLEASE SIGN THAT YOU HAVE READ ALL THE QUESTIONS AND ANSWER FULLY.

Additional Comments or Message

Signed

Date