Health & Safety Questionnaire (PAR-Q)
Please take a minute to fill in the following info
First Name
Last Name
Address
Email
Phone Number
Do you have a doctor’s permit to participate in physical activities?
Yes
No
Have you ever suffered from heart troubles
Yes
No
Are you presently taking any form of medication
Yes
No
Do you suffer from chest pains
Yes
No
Do you ever have spells of dizziness or feel faint?
Yes
No
Have you ever had either high or low blood pressure?
Yes
No
Have you ever had high cholesterol levels?
Yes
No
Have you ever had asthma, chronic bronchitis or any other chest aliments?
Yes
No
Do you suffer from severe back pains or any orthopaedic problems?
Yes
No
Do you suffer from severe headaches or migraines?
Yes
No
Are you recuperating from a recent illness, operation or injury?
Yes
No
Do you have any medical conditions that I should to be aware of?
Yes
No
Are you pregnant?
Yes
No
Do you suffer from pain or limited movement in any joints?
Yes
No
Are you currently under the care of any of the following: Chiropractor, Osteopath, Physiotherapist, Physical Therapist?
Yes
No
Is there any history of heart disease in your immediate family (under the age of 55 years old)?
Yes
No
Please note: if you answered YES to any of the questions above, you are advised to seek medical advice/approval before commencing an exercise induction or exercise programme, or consult further with your instructor.
Please give further details if you have answered yes to any of the above questions. Please include any health problems not already highlighted above that many affect the ability to exercise.
The teacher can accept NO liability for personal injury related to participation in a session if: Your doctor has, on health grounds, advised you against such exercise. You fail to observe instructions on safety or technique.
Your Signature
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