Physical Activity Readiness Questionnaire (PAR-Q)

Name *

First

Last

Address *

Telephone Number *

Email *

Age *

Emergency Contact Name, Telephone Number and Relationship *

Please complete the questionnaire below by reading each question carefully and ticking the response that applies to you. You are wholly responsible for your answers and if you are in any doubt you must seek medical advice.

1. Has your doctor ever said that you have a bone or joint problem, such as arthritis, or do you have any medical condition, surgical operation or injury that has been aggravated by physical activity or might be made worse with exercise? *

Yes
No

2. Do you have high or low blood pressure? *

Yes
No

3. Do you have Diabetes Mellitus or any other metabolic disease? *

Yes
No

4. Has your doctor ever said you have raised cholesterol (serum level above 6.2mmol/L)? *

Yes
No

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

Yes
No

6. Have you ever felt pain in your chest when you do physical activity or at rest? *

Yes
No

7. Is your doctor currently prescribing you medication? *

Yes
No

8. Have you ever suffered from unusual shortness of breath at rest or with mild exertion? *

Yes
No

9. Is there any history of coronary heart disease in your family? *

Yes
No

10. Do you often feel faint, have spells of severe dizziness or have you ever lost consciousness? *

Yes
No

11. Do you suffer from regular headaches, dizziness, fainting or fits? *

Yes
No

12. Are you, or is there any possibility that you might be pregnant? *

Yes
No

13. Do you have any other medical condition(s) that may make it dangerous for you to participate in physical activity/exercise? *

Yes
No

Please tick to confirm that you have read and accept The Focal Space Terms and Conditions *

I have read and I accept The Focal Space Terms and Conditions