PAR-Q Form

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PAR-Q Form

Client Name *

Age: *

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

Yes

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

Yes

In the past month, have you had chest pain when you were not performing any 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 that could be made worse by a change in your physical activity?
*

Yes

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

Yes

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

PLEASE READ AND CONFIRM BELOW STATEMENT:

I certify that my answers to the questions above are true and complete to the best of my knowledge. I understand and agree that it is my responsibility to inform my Trainer of the conditions or changes in my health, now and on-going, which might affect my ability to exercise safely and with minimal risk of injury. I also sign to say that I have sought medical advice on any/all questions within this PAR-Q form that I have answered ‘YES’ to and have been cleared to partake in the upcoming advised exercise programme.

YYYY

Confirm you have read the above statement: *

Yes

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