Pre-activity Readiness Questionnaire (PARQ)

Fitness Classes

Personal Details

Full Name *

Address *

City *

Postal code

Country *

Phone *

Email *

Date of birth *

Emergency Contact-Name *

Emergency Contact-Number *

Medical Information

1. Do you have any injuries, aches and pains? (Recent or old) *

2. Do you have any other health concerns e.g. asthma, diabetes, high blood pressure or any other condition for which you take medication? *

3. Are you presently having any kind of therapy? E.g. massage, physio, chiropractic *

4. Are you involved in any sport, physical activity or exercise program? *

5. What is your occupation? *

6. Do you have any pelvic health issues? *

7. Do you suffer from osteo/rheumatoid arthritis? If so which joints are affected? *

8. Do you have any problems with bones? (Osteoporosis or height loss?) *

9. Do you have any back problems? *

10. Can you get down to the floor unaided? *

11. Are you taking any medications? If so, please indicate which medications and for which conditions *

12.Considering the responses that you have given, do you believe that it is safe for you to participate in exercise? *

I acknowledge that I have not withheld any relevant information relating to my present health status. I understand that it is my responsibility to inform my instructor of any future changes in health that may occur or any problems that I experience when exercising. While safe and effective exercise may produce many health benefits, it is also important to realise that there is also a low possibility of exercise causing some difficulties. It is recommended that to avoid any risk, you start exercise at a low level and gradually build up fitness. Initially you may experience some local muscular soreness and slight fatigue, but as the programme continues, they should disappear. I understand the risk involved and undertake to inform my instructor should any issues arise. *