Physical Activity Readiness Questionnaire (PAR-Q)
Please read each question carefully and answer each one honestly.

Moderate or vigorous exercise should not be a hazard for most people providing it is undertaken as part of a regular program starting from low intensity and progressing gradually. However, some people will need medical evaluation and advice before starting a program, some may need to exercise under medical supervision and some people may only be able to undertake restricted physical activity under medical supervision.

If you answer NO to all the questions, it is reasonable for you to assume that you are in a suitable physical condition to start a regular graduated exercise program.

If you answer YES to one or more question you are first advised to consult your doctor prior to participating in any exercise program

Please complete the LM FIT Questionnaire, PAR-Q, Liability Waiver & T&Cs form. If you have any questions please send an email to leishamulveyfit@gmail.com
Full Name *
Next of Kin & Relation *
Next of Kin Contact Number: *
Has your doctor ever said that 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 chest pain when you are not doing physical activity? *
Do you lose your balance because of dizziness or do you ever lose consciousness? *
Do you have a bone or joint problem that could be made worse by a change in your physical activity? (Examples: back, hip or knee) *
Is your doctor currently prescribing drugs for your blood pressure or heart condition? *
Do you know of ANY OTHER REASON why you should NOT do physical activity? *
If you answered yes to any of the above questions please describe in more detail as to why you answered "yes".
"I have read, understood and completed the questionnaire. By selecting 'Agree' it will act as my signature on this questionnaire." *
Signature (Full Name) / Date / Contact Telephone Number. *
By signing electronically below I affirm that the above statements are true to the best of my knowledge. Please type your full name below. By typing and submitting, this serves as a Digital Signature. This digital signature holds the same authority as a handwritten one. Thank you.
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