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Pram - Exercise Readiness Questionnaire - PAR-Q
 

Please complete all details.


First Name:
Last Name:
E-mail:
Address Line1:
Address Line2:
Address Line3:
Town/City:
County:
Post Code:
Home Telephone:
Work Telephone:
Mobile:
Emergency Contact Name:
Emergency Contact Telephone:
GP Name:
GP Telephone:
DOB:
Sex: Male Female
Safety of all clients training with us is of paramount importance. For this reason we must establish your current health status prior to helping you improve your fitness. The questions below are designed to identify those persons who should obtain medical advice before undertaking physical exercise and will also help us to prescribe the most effective fitness programme for you. Whilst every care will be given to the best of the trainers' ability, it is up to the individual to know his / her limitations. All information given will be treated with the strictest confidence.
Part 1 - Please click the relevant boxes below?
Q1: Has your GP ever diagnosed a heart condition or recommended medically supervised only exercise? Yes No
Q2: Do you suffer from chest pains, heart palpitations or tightness of the chest? Yes No
Q3: Have you been seeking medical attention for any other conditions? Yes No
If you answered YES to the questions above please give brief details:
Details:
Q4: Do you have known high blood pressure? Yes No
If you answered YES to the question above please give brief details:
Details:
Part 2 - Please click the relevant boxes below?
Q5: Do you have low blood pressure or often feel faint or have dizzy spells? Yes No
Q6: Have you ever had any bone or joint problems, which would be aggravated by physical activity? Yes No
Q7: Do you suffer from diabetes?
If yes, are you insulin dependant?		 Yes No
Yes No
Q8: Do you suffer from any chest problems i.e. Asthma, Bronchitis, or Emphysema? Yes No
Q9: Do you suffer from Epilepsy? Yes No
If yes, when did you last have a fit?                                     Select month please
Enter year please    
Q10: Have you had your 6 week post natal checkup? Yes No
Q11: Have you participated in any regular exercise in the past? Yes No
Q12: Are you on any medication or have you recently had an illness? Yes No
If you answered YES to the questions above please give brief details:
Details:
Q13: Have you had any injuries in the past, e.g. back problems or muscle, tendon or ligament strains etc? Yes No
If you answered YES to the question above please give brief details:
Details:
Q14: Is there any other reason, not already mentioned, which may affect your ability to exercise? Yes No
If you answered YES to the question above please give brief details:
Details:
PLEASE NOTIFY YOUR PERSONAL TRAINER OF ANY CHANGES IN YOUR HEALTH STATUS
I have read and fully understand the exercise Readiness Questionnaire - PAR-Q.
I confirm, to the best of my knowledge, the answers given are correct and accurate. I know of no reason, unless stated otherwise above, why I should not participate in an exercise workout. I understand that I would be starting group personal training with PT-ME in the Park entirely at my own risk and waive any legal resource for damages to myself or property arising from my participation.
I will also give a months notice should I wish to no longer participate in the group training sessions
YOU AGREE TO THIS BY THE SUBMIT BUTTON BELOW