Sanjuro Physically Active Readiness Questionnaire (PARQ)
Becoming more active is safe for most people, but if you are in doubt, please consult with your doctor before starting this activity. If you answer YES to any questions then you must speak with your doctor before you start and bring a letter from them giving you permission to take part in the training.

If you are over 60 years of age and are not used to being physically active then you must speak with your doctor first.

If your health changes so that your answer changes to Yes for any of the questions then please
 notify your instructor and seek advice from your doctor.
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Full Name *
Gender *
Age *
Date of Birth *
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Email *
Phone number *
Post Code *
House / Flat number *
Emergency contact name *
Emergency contact telephone number: *
Please let us know if you have any sensory impairments which may impact on your class experience with us.
Would you say you are deaf or hard of hearing? *
Do you have a visual impairment *
If the answer is yes to visual impairment please mark your preferred communication for this class
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Has your doctor ever said that you have a heart condition and that you
 should only do physical activity recommended by them? *
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? *
Do you suffer shortness of breath? *
Do you suffer from light-headedness or fainting? *
Are you currently on medication for your blood pressure or a heart condition? *
Are you pregnant or suspect you could be pregnant? *
Have you been diagnosed with cancer, osteoporosis, emotional disorders,
 eating disorders, edema? *
Within the last year have you attended hospital or undergone surgery? *
Do you know of any other reason why you should not do physical activity? *
Date Completed *
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