Twinspire Par-Q

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Twinspire Par-Q

Health Questionnaire

Email *

Name *

Date of birth *

YYYY

Are you currently feeling unwell and/or have a temperature? *

Yes

Has a Doctor ever said that you should not take part in physical activity? *

Yes

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

Yes

Do you ever feel pain in your chest when not doing physical activity? *

Yes

Is there a history of heart conditions in your family? *

Yes

Do you ever feel dizziness or light headed? *

Yes

Are you on any medication for blood pressure? *

Yes

Are you currently taking any other medication? *

Do you suffer from any pain in your lower back? *

Yes

Are you or have you been pregnant in the last 6 months? *

Yes

Has your doctor ever said that you have a bone or joint problem that could be made worse by physical activity? *

Yes

Can you think of any other reason why you should not take part in physical activity? *

Is there anything that you would like to elaborate on in relation to any of the above questions?

Please provide ‘in case of emergency’ contact details (name & phone number)

I accept that it is the responsibility of the attendee to inform the instructor of any changes to my health condition that could affect my ability to exercise and/or be worsened by exercise. I will also inform the instructor of any changes to the medication I am taking. *

Yes I accept

No I do not accept

A copy of your responses will be emailed to the address you provided.

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