Physical Activity Readiness Questionnaire (PAR Q) Name * First Name Last Name Date Of Birth * Address Email * Telephone * Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor? * Yes No Do you feel pain in your chest when you do physical activity? * Yes No In the past month, have you had a chest pain when you were not doing physical activity? * Yes No Do you lose balance because of dizziness or do you ever lose consciousness? * Yes No Do you have a bone or joint problem (for example back, knee or hip) that could be made worse by a change in physical activity? * Yes No Is your doctor currently prescribing medication for your blood pressure or heart condition? * Yes No Do you know of ANY OTHER REASON why you shoul not take part in physical activity? * Yes No If "YES" please comment If you answered YES to one or more questions: You should consult with your doctor to clarify that is is safe for you to become physically active at this current time and in your current state of health. If you answered NO to ALL or the questions It is reasonably safe for you to participate in physical activity, gradually building up from you 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 or exercise, and my participation involves a risk of injury. Signature * Date * Having answered YES to one of the questions above, I have sought medical advice and my GP has agreed that I may exercise. Signature * Date * This PAR Q becomes invalid should your condition change Thank you!