Bodymode Physical Activity Readiness Questionnaire (PAR-Q)
Being active is safe and fun for most people. This PAR-Q is designed to identify the small number of adults for whom physical activity may be inappropriate or those who should seek medical advice concerning the type of activity that they should undertake. Please read the following questions carefully and check the answer that applies to you. Please also make your instructor aware of any medical problems or injuries that you have. All information held is treated as confidential.
Full Name *
Your answer
Age *
Your answer
Address *
Your answer
Telephone No. *
Your answer
Occupation *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Telephone Number *
Your answer
How did you hear about Bodymode? *
Is there anything in your medical history that you feel could affect your ability to exercise? *
Your answer
Are you taking any medications? *
If so, please list
Your answer
Do you have any joint/back problems that can be made worse through exercise? *
Do you suffer with Osteoporosis /Arthritis? *
Are you preganant or post natal within the last 6 months? *
Do you suffer with high or low blood pressure? *
Do you have a heart or lung condition? *
Do you suffer with fainting or dizzy spells? *
Do you have any recent injuries or operations? *
Have you ever had an operation or injury which still affects you in any way? *
Please give further details to any questions you answered 'Yes'
Your answer
If you have been referred by a specialist (i.e. Osteopath) please supply details of any pre-existing conditions, giving names where possible:
Your answer
If you answered yes to one or more questions You should talk to your Doctor before you start to become more physically active. Tell your Doctor about the questionnaire and which questions you answered yes to. Please also tell your instructor. If you already have medical clearance for fitness classes and moderate exercise in general, please fill in the declaration form below. *
Required
If you answered No to all the questions You can be reasonably sure you are fine to commence with the classes. However, if your health or fitness changes subsequently to answering No to these questions, please inform your Instructor at the beginning of class.I have read, understood and completed this questionnaire. *
Required
I declare that I am ready to undertake a fitness programme and have been cleared by my doctor if required. *
Required
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