Be Healthy Active 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.

Name and Surname *
Your answer
Contact Number *
Your answer
Email address *
Your answer
Address and Post Code *
Your answer
Emergency Contact name *
Your answer
Emergency Contact number *
Your answer
Have you ever had chest pain when you were not doing physical activity? *
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? *
Do you ever feel pain in your chest when you do physical activity? *
Do you ever feel faint or have spells of dizziness? *
Do you have a joint problem that could be made worse by exercise? *
Have you ever been told that you have high blood pressure? *
Are you currently taking any medication of which we should be made aware? *
Are you pregnant or have you had a baby in the last six months? *
Is there any other reason why you should not participate in physical activity? *
If you have answered YES to one or more questions, please provide details:
Your answer
If you have answered YES to one or more questions: *
It is recommended you talk to your doctor by telephone or in person before you start becoming more physically active (including having a fitness assessment). Tell your doctor about the questionnaire and which question(s) you answered “yes” to. You may be able to do any activity you want, as long as you begin slowly and build up gradually, or you may need to restrict your activities to those which are safe for you. Talk to your doctor about the kind of activity you wish to participate in and follow his or her advice.
Required
If you have answered NO to all questions: *
You can be reasonably sure that you can start to become more physically active and take part in a suitable exercise programme but remember: begin slowly and build up gradually.
Required
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.
Required
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 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.
Required
Communication *
James Berman, Be Healthy Active, would like to stay in touch with you including and not withstanding via email, SMS or WhatsApp. I need your permission to do this. You can change your mind at a later date by 'Unsubscribing' to emails or contacting me 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 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 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.
Submit
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