Be Healthy Active Pre and Post Natal Physical Activity Readiness Questionnaire (PAR-Q)
Read and complete the information below then press 'Submit' on completion.

If you are planning to take part in physical activity or an exercise class, start by answering the questions below. If you are between the ages of 15 and 69 the questionnaire will tell you if you should talk to your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.

All information will be treated confidentially.

Informed Use of the PAR-Q: James Berman, Be Healthy Active and agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire consult your doctor prior to physical activity.

First name & surname *
Your answer
Email address *
Your answer
Mobile number *
Your answer
Address and Post Code *
Your answer
Emergency contact name *
Your answer
Emergency contact mobile number *
Your answer
1. Have you been cleared to participate in exercise by your doctor/midwife? *
2. Do you have, or have you ever had, a heart condition, high blood pressure or circulatory problem? *
3. Do you have diabetes, asthma or epilepsy? *
4. Do you ever feel faint or suffer from dizzy spells? *
5. Do you ever experience pain in your chest when exercising or at rest? *
6. Are you aware of any condition / injury that may give reason for us to modify your exercise programme? *
7. Are you currently taking any prescribed medications? *
8. Have you had any surgery in the past year that may affect your physical activity? *
9. Are you currently pregnant? *
If yes, how many weeks / months?
Your answer
10. How postnatal are you at the time of filling out this questionnaire? *
In weeks or months
Your answer
11. Method of delivery? *
12. Did you have any complications? E.g. assisted delivery, blood transfusion *
13. Are you currently breast feeding? *
14. Have you miscarried in the past? *
15. Do you / have you suffered from any pelvic pain? *
16. Do you/ have you suffered from any lower back pain? *
If you answered YES to any of the health questions, please provide brief detail.....
It is recommended to talk with your doctor or health professional by phone or in person BEFORE you start becoming more physically active. Talk to your doctor about the PAR-Q, which questions you answered YES to and the kinds of activities you wish to participate in and follow his/her advice.
Your answer
If you answered NO to all of the questions *
If you answered NO to ALL the questions, you can be reasonably sure that you can start becoming more physically active, start slowly as this is the easiest and safest way to go.
Please note: If your health changes so that subsequently you answer “yes” to any of the above questions: *
Inform your fitness or health professional immediately. Ask whether you should change your physical activity or exercise plan. Delay becoming more active if you feel unwell because of a temporary illness such as a cold or flu – wait until you are better.
Informed Consent *
The purpose of an exercise activity is to help you achieve your health and fitness goals. You will experience some feelings of exertion during each activity session and may become hot and uncomfortable at times. You can expect your breathing to become more rapid and your heart rate to increase. As your fitness improves, your goals may lead you to participate in more vigorous levels of activity, but these should remain within your capabilities. All activities will be explained to you and demonstrated, but you should feel free to ask any questions you may have. Any exercise activity carries with it an element of risk. The sessions are designed to minimise risk yet, at the same time, provide an effective exercise/ activity. Please inform the instructor if there is any reason at any time why you should not participate in an activity; for example, an illness or an injury which might be aggravated by exercise. If, at any time, you feel undue pain or excessive discomfort stop the activity immediately and inform the instructor of your symptoms. You are free to withdraw from any activity at any time you wish.
Communication *
James Berman, Be Healthy Active would like to stay in touch with you including and not withstanding via email, SMS or WhatsApp. We need your permission to do this. You can change your mind at a later date by 'Unsubscribing' to emails or contacting us directly. Please tick a box below to confirm your contact preference. Please note that use of the booking system means you will receive an email to confirm your booking; receive a reminder of your booking or receive notification of a class cancellation. This cannot be prevented from happening without impact to the entire booking system.
Photos and Videos *
James Berman, Be Healthy Active may take photos and videos during your activities and sessions from time to time. These will be used for promotional purposes on social media applications including and not withstanding Facebook, Instagram and Twitter. I would like your permission to do this. Please tick the box/es below to confirm if you are happy for images / videos of yourself to be shared on social media applications.
Declaration *
Agree / Confirm
I know of no reason why I should not participate in an exercise programme. I have obtained confirmation from my General Practitioner or Health Professional that it is safe and appropriate for me to begin an exercise programme. I understand that I take part at my own risk and I waive any legal recourse for damages to myself, my child or property arising from participation.
I agree to take part in the activity session as described to me by the instructor. The nature, purpose, risks and benefits have been explained to me and I understand what is required of me and that I may withdraw at any time.
I confirm that have read, understood and completed this questionnaire myself.
I confirm that all questions have been answered to the best of my knowledge.
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