Project HB ParQ & Consent Form
A form to fill in to confirm your are in adequate health and to confirm that you understand the risks involved in physical activity, before taking part in an exercise class with Carly Wilkinson under the brand Project HB.

Why collect this data? Asking you to accept the risks of physical exercise means my professional indemnity and public liability insurance is valid, which I need in order to teach you safely and legally. I also gather a little data on your current health and fitness levels, which helps me plan a class tailored to you and your needs. The contents of this form, protects us both.

What do I do with your data? I store form securely for 3 years from the day you signed last attended an exercise session with me, upon which point your data will be permanently deleted. If you want me to delete your data before this cut off time, please email me at projecthb@live.co.uk requesting this, and I will delete all data I have stored about you, immediately.

Please note: You may need to complete this form again, if you request I delete your data, and then want to attend another class.

Provide your full name *
Your answer
Provide your email address *
Your answer
Provide your telephone number *
Your answer
Provide the full name, relationship and contact number of your emergency contact *
Your answer
1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *
Required
2. Do you feel pain in your chest when you do physical activity? *
Required
3. In the past month, have you had chest pain when you were not doing physical activity? *
Required
4. Do you lose your balance because of dizziness or do you ever lose consciousness? *
Required
5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? *
Required
6. Is your doctor currently prescribing drugs for your blood pressure or heart condition? *
Required
7. Are you in the first trimester of pregnancy or do you suspect that you might be pregnant? *
Required
8. Do you know of any other reason why you should not do physical activity? *
Required
Taking part in physical exercise
IF YOU ANSWERED YES TO ONE OF MORE QUESTIONS ABOVE, talk with your doctor by phone or in person BEFORE you start becoming more physically active or BEFORE you take part in a fitness session. Tell your doctor about which questions you answered YES.
- You may be able to do any activity you want - as long as you start slowly and build up gradually. Or you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
- Find out which community programmes are safe and helpful.

IF YOU ANSWERED NO, HONESTLY, TO ALL QUESTIONS ABOVE, you can be reasonably sure that you can:
- Start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
- Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you live actively DELAY BECOMING MUCH MORE ACTIVE
- If you are not feeling well because of a temporary illness such as a cold or a fever - wait until you feel better.
- If you are or may be pregnant - talk to your doctor before you start becoming more active.

Please Note:
If your health changes so that you answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. If in doubt after completing this questionnaire, consult your doctor prior to physical activity.

CONFIRMING YOU HAVE UNDERSTOOD THE QUESTIONS ABOVE: Type your name to confirm the following: I, the undersigned have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. *
Your answer
GIVING CONSENT TO PARTICIPATE: Type your name to confirm the following: I, the undersigned understand the exercise session that I will perform and the associated risks and discomforts. Knowing these risks and discomforts, having understand that I am free to cease exercising at any point during the session and that I have the opportunity to ask questions throughout. I consent to participate in this exercise session. *
Your answer
Date signed *
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