Medical Questionnaire

Medical Questionnaire

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 your physical activity patterns. If you are over 69 years of age and are not used to being very active, check with your doctor. Common sense is your best guide when answering these questions. Please read carefully and answer each one honestly: check YES or NO.

Your name*

Your email*

Telephone number*

Date of birth*

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?

YesNo

Do you feel pain in your chest when you do physical activity?

YesNo

In the past month, have you had a chest pain when you were not doing physical activity?

YesNo

Do you lose you balance because of dizziness or do you ever lose consciousness?

YesNo

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?

YesNo

Is your doctor currently prescribing medication for your blood pressure or heart condition?

YesNo

Do you know of any other reason why you should not do physical activity?*

YesNo

If yes, please provide your reasons:

YES to one or more questions:
You should consult with your doctor to clarify that it is safe for you to become physically active at this current time and in your current state of health.

NO to all questions:
It is reasonably safe for you to participate in physical activity, gradually building up from your current ability level. A fitness appraisal can help determine your ability levels.

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.

Please draw in the box below to provide your signiture*

Print name*

Date*

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

Please draw in the box below to provide your signiture

Print name

Date

Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the 7 questions.