Celebrity Circuits PAR-Q Form

Celebrity Circuits Health and Safety Form

The benefits of regular physical activity are widely recognised. Not only does it improve your health and wellbeing, but it is fun too.

Whilst exercise is very safe for most people, it is necessary for some individuals to check with their doctor before increasing their activity levels.

Please be honest when answering these questions, for your own health and safety.

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* 1. Please tick the box if answering YES to any of the following questions:

Has your doctor ever said that you have a heart condition?

Do you have pains in your chest when performing physical activity?

Have you had chest pain when you were not doing physical activity?

Do you lose your balance due to dizziness, or ever lose consciousness?

Is there a history of coronary disease in your immediate family?

Do you suffer from high or low blood pressure?

Do you suffer from high cholesterol?

Are you pregnant now or have you given birth within the last 6 months?

Have you had surgery recently?

Do you have any chronic illness or physical limitations such as Asthma, diabetes?

Do you have any injuries, bone/joint or orthopedic problems such as bad knees, back, shoulder, wrist or neck issues?

Do you take any medications, either prescription or non-prescription regularly?

Do you suffer / have you suffered from eating disorders?

Do you drink alcohol?

Do you smoke?

Do you know of any other factor that may affect your ability to participate in physical activity?

If you have ticked any of the above, please elaborate below:

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* 2. If there is any additional information that you would like us to know please add this here:

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* 3. If you have had a baby in the last 12 months, please answer the following questions:

Did you have a C-section?

Did you have an episiotomy?

Are your breast feeding?

Are you getting up at night?

Are you napping/resting during the day?

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* 4. Sometimes Celebrity Circuits posts pictures from our BabyFit and Buggy Burn classes on social media to show other mums what the classes are all about. Are you happy for your baby to be featured in social media posts (e.g. photos, videos)?

Yes

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* 5. Please enter the name and contact number of someone who we can contact in the event of an emergency:

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* 6. DISCLAIMER

If you answered YES to one or more questions

Talk with your doctor by phone or in person before you start becoming much more physically active and before you begin training with Celebrity Circuits as participation can be refused. Tell your doctor about the PAR-Q, your intended training and to which question(s) you answered YES.

If you answered NO to all questions

If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can start becoming more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.

I confirm I have read and understood this PAR-Q and have completed it to the best of my knowledge.

I confirm that if I answered YES to any questions I will seek advice from my doctor BEFORE taking part in a Celebrity Circuits training session.

I confirm that if my health changes so that I then answer YES to any of the above questions it is my responsibility to inform Celebrity Circuits and complete a new PAR-Q.

Yes

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* 7. ADDITIONAL DISCLAIMER - POST-NATAL CLIENTS ONLY

This questionnaire has been completed accurately to the best of my knowledge and belief.

I can confirm that I have had the all clear by my GP to commence suitable postnatal exercise.

I am aware that I must feel well prior to each class and will notify you (the trainer) should I feel unwell at any time during the class.

Whilst I am aware that every effort has been taken to ensure this exercise class is suitable for post-natal clients, I understand that my participation and the safety of both my child/children and myself are my responsibility.

Yes

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* 8. Participant Contact Details

Name *

Address *

Address 2

City/Town *

County

Postal Code *

Country

Email Address *

Phone Number *