Physical Activity Readiness Questionnaire

This PAR-Q has been designed to identify anyone who may need to seek medical advice concerning the type of activity most suitable for them or for whom physical activity may be inappropriate.

By filling out this form you are confirming that where any medical condition, discomfort or injury which may be affected by physical activity applies or becomes applicable at any time when you are participating in a class, you are responsible for checking with your own doctor to ensure you are able to participate in this activity.

If you should answer YES to any of the following questions you are required to gain consent from your doctor before participating in the group exercise class.

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

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* 2. Do you feel pain in your chest when you do physical activity?

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* 3. In the past month, have you had chest pain when you were not doing physical activity?

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* 4. Do you lose your balance because of dizziness or do you ever lose consciousness?

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* 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change of physical activity?

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* 6. Is your doctor currently prescribing medication (for example, water pills) for your blood pressure or heart condition?

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* 7. Do you know of any other reason why you should not do physical activity?

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* 8. Name and contact number

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* 9. Date of birth

Date

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* 10. Emergency contact information - name and number

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