GFBS Health PARQ
Get Fit Be Strong Pre exercise health questionnaire
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Participants Name *
Email *
Contact number *
Date of birth *
MM
/
DD
/
YYYY
Emergency contact name *
Emergency contact number *
Do any of the following apply to you
Please check YES or NO
1. Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *
2. Have you ever felt pain in your chest when you do physical exercise? *
3. Do you often feel faint, have spells of severe dizziness or have lost consciousness? *
4. Have you ever suffered from unusual shortness of breath at rest or with mild exertion? *
5. Has the your doctor ever said that you have a bone or joint problem, such as arthritis, that has been aggravated by exercise or that may be made worse by exercise? *
6. Is there a good physical reason, not mentioned here, why you should not follow an activity program even if you wanted to? *
If yes, please state here:
7. Are you or have you been pregnant in the past 6 months? *
8. Are you currently on any prescribed medicines that may affect your ability to exercise? *
9. Do you suffer from any problems of the lower back, i.e. chronic pain or numbness? *
If yes, please state here:
10. Do you currently have a disability or a communicable disease? *
If yes, please state here:
Your answers
If you answered YES to one or more questions: You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

If you answered NO to all questions: It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.
Client Name *
Parent/Guardian Name (if Under 18)
Electronic signature of Client or Parent/Guardian (if under 18) *
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