PARQ
Physical Activity Readiness Questionnaire

My PAR-Q is designed to help you to help yourself if you are between the ages of 16 and 69.  For most people, physical activity should not pose a problem or hazard.  PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.  Common sense is your best guide in answering these few questions.  Please read them carefully and check the correct answer opposite the question.

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Email *
Is it OK to add your e-mail to my newsletter list?  Please note that I will not pass your e-mail address on. *
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Name: *
Phone Number: *
Address: *
Date of Birth *
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Emergency Contact Name & number *
Has your doctor ever said you have heart trouble? *
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Do you frequently have pains in your heart or chest *
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Do you tend to lose consciousness or fall over as a result of dizziness? *
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Do you have a bone or joint problem that could be or has been aggravated by exercise? *
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Has your doctor ever recommended medication for blood pressure or heart condition? *
Required
Are you aware, through your own experience or a doctors advice, of any other physical reason against your exercising without medical supervision? If YES, please add details to the bottom of this form. *
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Are you over the age of 65 and not accustomed to vigorous exercise? *
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Are you currently pregnant, or have been pregnant within the last 6 months? *
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If you answered YES to one or more of the above questions, please answer the following questions:
Have you consulted with your physician regarding increasing your physical activity and/or performing a fitness assessment?
If you answered NO to question 9, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?
If you have answered YES to one or more questions above, then 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.
Do you currently exercise? If yes, what do you do & how many hours per week?
Injuries to pelvic area (inc radiotherapy, episiotomy, etc)
Clear selection
Do you have a chronic cough or sneeze (hayfever, asthma, smoker)
Clear selection
Do you suffer with constipation (IBS/Crohns/IBD/Other)
Clear selection
Overweight BMI over 25
Clear selection
Do you leak urine on exercise, cough, laugh etc?
Clear selection
Constantly need to go to the toilet
Clear selection
Find it difficult to empty your bladder or bowel (or just feel unfinished)
Accidentally lose control of bowel
Clear selection
Do you have a prolapse (feeling of heaviness, dropping or bulge)
Pelvic pain or pain with intercourse
Clear selection
Do you have any prostate issues?
Have a Diastsis Recti (Ab Separation)? If yes, what size is it?
Have you seen a Women's Health Physio or other Specialist?
Clear selection
Number of pregnancies
Menopause
Have you had any gynaecological surgery?
Please tick any of the following that apply to you, further details can be provided in the box below.
Column 1
Asthma
Arthritis
Back Pain
Angina
Dizziness/Fainting
Diabetes Type 1/2
Epilepsy
Heart Disease
High Blood Pressure
Low Blood Pressure
Joint Pain
Muscular Tension
Any Further Details:
COVID-19 (Coronavirus) - The health and safety of myself and my clients are always my number one priority.  Due to the recent coronavirus outbreak and in line with government advice, if you are, self-isolating, experiencing or displaying any symptoms (high temperature/new, continuous cough/loss or change to your sense of smell or taste ) of coronavirus or have knowingly come in to contact with anyone who has, I ask that you inform me & DO NOT attend your in-person session.  If you do experience or display any symptoms of coronavirus and have attended the studio within the previous 14 days I ask that you inform me immediately so that I can take any necessary precautions. *
Required
I have read, understood and accurately completed this questionnaire.  I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.  I will work at an appropriate level for myself and stop if I feel pain or discomfort and inform my instructor.  This PAR-Q is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes.  It is your responsibility to inform the instructor about any changes in your health. *
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Cancellation policy: 24 hours notice is required to reschedule your 1 to 1 session, otherwise the missed session will require full payment.  Group Class packages & 1 off PT sessions must be used within 5 months.  Block bookings require payment in full in advance. *
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