Joanne Roche Pilates & Fitness

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PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR Q) (August 2024)

Email *

Name: *

DOB: *

YYYY

Address: *

Telephone Number: *

Occupation: *

Medical Health Check *

Yes

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

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

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

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

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Are you pre or post natal?

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Do you know of any other reason why you should not take part in physical activity?

Yes

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

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

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

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

Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Are you pre or post natal?

Is your doctor currently prescribing medication for your blood pressure or heart condition?

Do you know of any other reason why you should not take part in physical activity?

Medical Health Check - If you answered yes to any of the questions, or would like to add any additional information or health details not covered by this form, please provide further details below.

If you have nothing to add please put n/a

Disclaimer

If you answered YES to one or more questions:
Talk with your doctor before commencing a fitness programme. You may be able to do an activity as long as you start slowly and build up gradually. Or you may need to restrict your activities to those which are safe for you.

If you answered NO to all of the questions:
You can be reasonably sure that you can start to become more physically active - begin slowly and build up gradually.

If your health or fitness changes subsequently to answering no to these questions, please inform your Instructor at the beginning of class.
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.

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Date Completed: *

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