PHYSICAL ACTIVITY READINESS QUESTIONNAIRE

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Please complete this prior to joining any VanessaPT.com classes (ONLINE & IN PERSON)

NAME *

ADDRESS *

EMAIL *

Date of Birth

YYYY

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Please read the questions carefully and answer each one honestly: check YES or NO

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Do you know of any other reason why you should not participate in physical activity? *

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 the current time and in your current state of health. If you answered NO to one or more 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. 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. If you have answered YES to one of the questions above and have sought medical advice and your GP has agreed that you may exercise you must sign below. PLEASE SIGN BELOW.

DISCLAIMER : You will participate in virtual classes at your own risk. You confirm that you are fit and healthy with no injuries. Please ensure you have plenty of space around you to participate safely. I cannot be held responsible for any damage to your property or if you sustain any injuries whilst taking part virtually.

Name *

Date *

YYYY

Emergency Contact Details - Name & Number *

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