Physical Activity Readiness Questionnaire
Welcome to your BARN DANCE FITNESS (online) class. Regular physical exercise is fun and healthy and becoming more active is very safe for most people. Please fill in the assessment below; you can review your assessment at any time in the future. Any personal information is kept in strict confidence. Full details of privacy policy:
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Email *
First name *
Last name *
Mobile no
Seven Questions *
Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had a chest pain when you were not doing physical activity?
Do you lose balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing medication for your blood pressure or heart condition?
Do you know of any other reason why you should not take part in physical activity?
If yes...
If yes on any of the above questions, please elaborate here:
Your safety
Please note – your teacher is not a medical practitioner and cannot advise whether any condition could be adversely affected by attending this class. However your teacher reserves the right to suggest you do not participate in activity until discussion with a medical practitioner.

The responsibility lies with each participant to decide whether they wish to join or continue with a class, assisted by any medical advice they may wish to obtain.
In case of...
In case of emergency, who would you like us to contact?
Their phone no...
Statement *
I have read , understood and accurately completed this questionnaire. I confirm that I am voluntarily engaging in an acceptable level of exercise, and my participation involves a risk of injury.
A copy of your responses will be emailed to the address you provided.
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