Healthiness Ltd Physical Activity Readiness Questionnaire (PAR-Q)
We would like to know a bit about your health and wellbeing and about the amount you exercise each week. This information will help us in providing the best services and activities for you, so please complete each question as accurately as you can. All information you provide with be for the use of Healthiness Ltd only. Many thanks.
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What class or type of exercise are you interested in participating?
Name *
Address (with post code) *
Date of Birth *
Contact email/mobile/phone number *
Emergency contact name and mobile number
1. Do you consider yourself to have a disability?
2. If you have a long term condition, illness or infirmity please tick the relevant boxes below. (Long-term; anything that has troubled you over a period of time, or that is likely to affect you over a period of time that cannot at present be cured, but might be controlled by medication or other therapies). *
Required
If you have ticked 'other' to the question above, please provide further details
3. What is your ethnicity?
Clear selection
4. Physical Activity Readiness Questionnaire (PAR-Q). We need to know that you are ready to exercise, please answer the questions below. (Tick any that apply to you)
If you ticked One or More of the questions above (question 4) you may need to TALK WITH YOUR DOCTOR about the PAR-Q before you start exercising. If you ticked yes to any of the above questions, please provide further details.
5. GP/ Health professional contact details
6. In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate slightly? This may include walking, gardening, housework and physical activity which is part of your job. *
7. In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate moderately? 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 which is part of your job. *
8. Rate your current thoughts and feeling against these statements (tick one box in each row)
None of the time
Rarely
Some of the time
Often
All of the time
I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling close to other people
I’ve been able to make up my own mind about things
I feel isolated from other people
I find it easy to get in touch with others when I need
I feel alone and friendless
Clear selection
9. What benefits would you like to achieve/ have achieved by participating in the Healthiness Ltd physical activity sessions; (tick any that apply)
Yes
Somewhat
No
Improved wellbeing
Improved mental wellbeing
Increased physical activity
Reduced social isolation
Improved social wellbeing
Improved awareness of own health
Clear selection
10. DISCLAIMER (part 1) We at Healthiness Ltd are here to keep you safe and make sure you are exercising correctly. It is YOUR RESPONSIBILITY to listen to instructions from the Healthiness instructor for your own safety. I agree to release Healthiness Ltd and my Medical Practitioner/Care Team from all claims, demands, damages and rights of action. I assume full responsibility for any injuries or damages which may occur during the Healthiness Ltd Facebook/Zoom online exercise sessions and face to face classes/activities. *
Required
11. DISCLAIMER (part 2) I understand I exercise at my own risk and if in doubt I agree to speak to my GP or Health Professional PRIOR to participating in the Healthiness Ltd Online exercise sessions and face to face exercise sessions. I will inform the Healthiness team of my medical condition. I will also tell Healthiness about any medication I am taking and any medical problem that I may have. *
Required
12. Thank you for taking the time to complete this questionnaire, if you have any further information you would like to add or anything you want to tell us please do so here.
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This form was created inside of Healthiness Ltd.