PARQ Form
Physical Activity Readiness Questionnaire
HEALTH QUESTIONAIRE
Full Name:
Date of Birth:
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· For most people physical activity should not pose any problem or hazard. This health
Questionnaire has been designed to identify the small number for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
· Please read the few questions below carefully and tick yes/no opposite the question that applies to you.
· If you answer yes to one or more questions, we may require you to obtain a clearance note from your GP.
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Please Tick |
YES |
NO |
Please Tick |
YES |
NO |
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Have you had any surgery in the past 12 months |
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Are you pregnant or have you recently given birth? |
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Do you suffer from epilepsy? |
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Do you suffer from bone/joint problems? (If yes please complete additional form) |
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Any Chest pains with/without Physical activity? |
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Any Allergies? |
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Severe headaches or Dizziness? |
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Heart problems? (If yes please complete additional form) |
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Backpain? |
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Do you have any current injuries? |
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High/low blood pressure? (If yes please complete additional form) |
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Are you on any medication? |
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Asthma attacks? |
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Is there any reason why you should not follow a graduated exercise programme? If yes, please state below. |
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Diabetes? (If yes please complete additional form) |
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Do you require an Induction? If no, please state reasons why |
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If you answered YES to one or more questions:
Please state reasons for stating yes to previous questions:
I have taken medical advice and my doctor has agreed that I should exercise and/or I have decided to exercise at my own risk
Signature: .
Date:
Declaration
I confirm that the information provided is correct. I agree to inform an instructor if in the event that the answer to any of the above question has changed. I also agree to only use the equipment that has been demonstrated to me by an instructor and will seek advice about the use of any equipment where I am unclear of its safe use. I understand that M Club and its employees will not except liability to injury caused where such injury is a result of my failure to use the equipment properly. My failure to seek advice about the proper use of the equipment as a result of mine or a third parties negligence.
I confirm that I wish to participate in a range of physical activities. These may include aerobic and resistance exercises and group exercises. I realise that my participation in these activities involves the risk of injury or potential medical complications. I hereby confirm that I am voluntarily engaging in physical exercise and shall do so at my own risk.
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Members Name: |
Fitness advisor name: |
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Members Signature |
Fitness advisor signature: |
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Date |
Date |
Blood Pressure
Please
confirm what medication you are currently on for Blood Pressure and any effects
this may have on you during physical activity?
Which
category of normal values do you fall between? Please circle below
Guidance
and definitions of Hypertension (Blood Pressure)
·
Average Blood pressure 135/85mmhg
·
Stage 1 Hypertension (mild) BP between 140/90mmhg
·
Stage 2 Hypertension (high) BP between 160/100mmhg
·
Sever hypertension BP is 180/110mmhg
National institute for health and
clinical excellence (NHS)
If your
score falls in the severe range, you are advised to seek medical advice before
you participate in any physical activity within the club and provide medical
certificates.
Declaration
I confirm
that I have read and fully understand the medical questions above. I also
confirm that I wish to participate in a range of physical activities These may
include aerobic, resistance exercise and group exercise. I fully realise that
my participation in these activities involves the risk of injury and potential
medical complications. I hereby confirm that I am voluntarily engaging in physical exercise and
shall do so at my own risk.
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Members Name: |
Fitness advisor name: |
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Members Signature |
Fitness advisor signature: |
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Date |
Date |
Coronary Heart Disease
CHD
Please
confirm what medication you are currently taking for your CHD and any effect
this may have on you during physical activity
Have you
ever suffered or are you suffering from:
·
Atherosclerosis: The build up of fatty (plaque)
deposits on the inner arterial walls resulting in reduced circulation and
elevated blood pressure.
·
Angina:
Chest pains caused by poor oxygen and nutrient supply to the heart often the
result of Atherosclerosis.
·
Heart Attack (Myocardial Infarction):Is the result of blood flow to the
heart being severely or completely restricted.
Have you ever had Heart surgery?
Have you been advised by your consultant that physical
activity will improve your condition and not have any detrimental effect on
your condition?
..
Declaration
I confirm
that I have read and fully understand the medical questions above. I also
confirm that I wish to participate in a range of physical activities These may
include aerobic, resistance exercise and group exercise. I fully realise that
my participation in these activities involves the risk of injury and potential
medical complications. I hereby confirm that I am voluntarily engaging in physical exercise and
shall do so at my own risk.
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Members Name: |
Fitness advisor name: |
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Members Signature |
Fitness advisor signature: |
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Date |
Date |
Bones and joint issues
Are you currently suffering from:
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Conditions |
Yes |
No |
Details |
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Arthritis |
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Osteoarthritis |
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Osteoporosis |
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Rheumatoid Arthritis |
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Fibromyalgia |
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Inflammation of joints |
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Had surgery requiring pins or plates |
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Have any acute injuries |
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Please confirm what (if any) medication you are currently taking for the treatment of your condition and any effects this may have on you during physical activity.
Declaration
I confirm that I have read and fully understand the medical questions above. I also confirm that I wish to participate in a range of physical activities These may include aerobic, resistance exercise and group exercise. I fully realise that my participation in these activities involves the risk of injury and potential medical complications. I hereby confirm that I am voluntarily engaging in physical exercise and shall do so at my own risk.
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Members name: |
Fitness advisors name |
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Members signature: |
Fitness advisors signature |
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Dates |
Dates |
Diabetes
Please
confirm what medication you are currently on for Diabetes and any effects this
may have on you during your physical activity.
At what
stage are you?
Guidance
and definitions of types of Diabetes.
·
Pre-Diabetic is the first stage of Type 2 Diabetes and involves higher than normal
blood sugar levels but not yet high enough to be classified as Diabetic.
·
Type 1 Diabetes or insulin dependent Diabetes is when the body cannot produce
insulin manually.
·
Type 2 Diabetes or adult-onset Diabetes is when an individual has led an
unhealthy lifestyle and their blood sugar levels are massively over normal
levels.
·
Gestational Diabetes can develop in some women that are currently pregnant and is
caused by hormonal changes resulting in an insulin shortage. This form of
Diabetes usually disappears after birth but can leave a higher risk of
developing Type 2 later.
Declaration
I confirm
that I have read and fully understand the medical questions above. I also
confirm that I wish to participate in a range of physical activities These may
include aerobic, resistance exercise and group exercise. I fully realise that my
participation in these activities involves the risk of injury and potential
medical complications. I hereby confirm that I am voluntarily engaging in physical exercise and
shall do so at my own risk.
.
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Members Name: |
Fitness advisor name: |
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Members Signature |
Fitness advisor signature: |
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Date |
Date |