Membership PARQ (Physical Activity Readiness Questionnaire)

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The purpose of this form is a self screening form to help you decide whether you are ready to exercise safely or require a medical check prior to exercise. This information will be kept for the period of membership, up to 12 months, and then destroyed. A designated committee data protection officer will be the sole data reviewer. If information received needs to be shared with coaches, this will not happen without your consent. It remains the responsibility of the individual member to update their session coach of any changes or anything they should be made aware of. The information will be stored on a password protected database.

Please answer YES or NO in the space provided. If YES please provide further details in the final question box.

Email *

Please confirm your name *

Please confirm your date of birth *

YYYY

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?: *

Yes

Clear selection

Do you feel pain in your chest when you do physical activity?: *

Yes

Clear selection

In the past month, have you had chest pain when you were not doing physical activity?: *

Yes

Clear selection

Do you lose your balance because of dizziness or do you ever lose consciousness?: *

Yes

Clear selection

Do you have any conditions with fluctuating or recurring effects (e.g. Epilepsy, MS)?: *

Yes

Clear selection

Have you ever suffered from unusual shortness of breath at rest or with mild exertion?: *

Yes

Clear selection

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart conditions?: *

Yes

Clear selection

Do you have a bone, joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?: *

Yes

Clear selection

Are you pregnant or have you had a baby in the past six months?: *

Yes

Not Applicable

Clear selection

Do you know of any other reason which could affect you being able to carry out or should not do physical activity?: *

Yes

Clear selection

Do you have any mobility difficulties or limb impairments?:

Yes

Clear selection

Do you have any visual impairment (not including general short/long sighted)?:

Yes

Clear selection

Do you have any hearing impairment?:

Yes

Clear selection

Do you have any developmental or learning difficulties?:

Yes

Clear selection

Do you have any mental health conditions?:

Yes

Clear selection

Details if you answered YES to one or more questions:

By submitting this form I agree that I am fit to train. I have sought medical advice prior to completing. If any of the information above changes you must inform the Coach prior to your session * *

YYYY

Send me a copy of my responses.

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