PARQ & Contact Form
The Physical Activity Readiness Questionnaire is designed to determine an individual's safety when starting a new exercise plan.
Please answer as honestly as possible!
First Name
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Last Name
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Phone
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Street Address
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Town / City
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State / County
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Postal code
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Country
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Country
Date of birth
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Emergency Contact Name
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Emergency Contact Number
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Emergency Contact Relationship
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1. Has your doctor ever said that you have a heart condition & recommended only medically supervised activity?
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2. Do you have chest pains brought on by physical activity?
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3. Have you developed chest pains in the last month?
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4. Do you tend to lose consciousness or fall over as a result of dizziness?
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5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
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6. Has a doctor ever recommended medication for your blood pressure or heart condition?
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7. Are you currently pregnant?
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If you have answered YES to any of these questions, please provide details below
I hereby state I have read, understood & answered honestly to the questions above. I understand participation in exercise involves the risk of injury & Katie will not be held liable.
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Submit
