Medical Questionnaire

Physical Active Readiness Questionnaire

Prior to participating in any fitness appraisal, workshop or other routine you are required to complete this PAR-Q together with the informed consent release and waiver form. For most people, physical activity should not pose any problem or hazard, however, potential risks, whilst not apparent at rest, may be exacerbated by an increase in levels of physical activity. The PAR-Q is designed to identify the small number of adults for whom physical activity might be inappropriate or those who +should seek medical advice concerning the type of activity most suitable for them. Please complete the questionnaire below by reading each question carefully and ticking the response that applies to you. You are wholly responsible for your answers and if you are in any doubt you must seek medical advice.

Name of Session*:

Name:*

Address*:

Contact Telephone Number*:

Emergency Contact Name*:

Emergency Contact Number:*

Please consider and answer the seven questions below as honestly as possible Please answer YES or NO below

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 drugs (for example, water pills) for your blood pressure or heart?*

Yes No

Do you know of any other reason why you should not do physical activity?*

Yes No

Please give details of any other medication you are currently being prescribed that you instructor should be aware of (e.g. inhaler):*

By ticking yes below and submitting this form I confirm that I have read, understood and to the best of my knowledge answered correctly the above questions. I understand it is my responsibility to inform my instructor of any changes to my health or medication which subsequently alter answers to any of the above questions, and that failure to disclose any relevant medical history is done so at my own risk. I understand that the onus is on me the participant to decide if an activity is suitable for me to participate in. Charnwood Borough Council assumes no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, you are advised to consult your doctor prior to participating I any physical activity.

Yes