Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Do you have any of the following conditions? *

If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you significantly change you physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Please read each question carefully and answer accordingly by ticking the box:

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?

Waiver

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. If applicable Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise..

I understand that by ticking this box I am signing this form and stating that all my details above are correct

If Applicable, I Have sought medical advice