Guiding Hands  - Physical Activity Readiness Questionnaire
Personal Data:

This form must be completed before any activities are undertaken as part of the project.  
These details will be stored securely and retained until the end of the programme, in compliance with the Data Protection Act 1998 and GDPR Guidance. This information will only be used for the evaluation of this project and for reporting to funders for monitoring purposes. 
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Name (optional)
Email
Postcode *
Contact number
D.O.B *
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Activity Level:
ETHNICITY. How do you describe your ethnicity? *
In the past week, on how many days have you done a total of 30 mins or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places but should not include housework or physical activity that is part of your job.
On a scale of 1-5, please choose the number that best reflects your current attitude to exercise.
I don’t enjoy exercise
I really enjoy exercising
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Health Questions:
If you are between the ages of 16 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: check YES or NO.
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *
Required
Do you feel pain in your chest when you do physical activity? *
 In the past month, have you had chest pain when you were not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness?
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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?
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Is your doctor currently prescribing medication for your blood pressure or heart condition?
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Do you know of any other reason why you should not do physical activity?
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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.
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.
Nearly ready to get started
*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.

*Having answered YES to one of the above, I have sought medical advice and my GP has agreed that I may exercise.

*I have checked my exercise space to ensure it is safe to participate in this online class.
Signed
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Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed.  
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