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Carpe Diem Fitness 2 Physical Activity Readiness Questionnaire (PAR-Q) Name: DOB: Sex: Address: Telephone: MOB: Email: Emergency contact Name & Tel: Common sense is your best guide for answering these questions. Please read them carefully and answer Y or N opposite the question as it applies to you. Questions Y/N 1) Do you have a bone or joint problem that may be aggravated by physical activity? 2) Do you suffer from High Blood Pressure? 3) Do you suffer from Low Blood Pressure? 4) Is there a history of Coronary Heart Disease in your family? 5) Is your doctor currently prescribing you drugs or medication? 6) Do you suffer from shortness of breath at rest or with mild exertion? 7) Do you have chest pains brought on by physical exertion? 8) Do you ever feel faint, have spells of severe dizziness or have lost consciousness? 9) Do you drink more than the average amount of alcohol per week (21 units for men/14 units for women)? 10 ) Do you currently smoke? 11 ) Are you, or is there any possibility you might be pregnant? 12 ) Are you over the age of 45 years? 13 ) Do you know of any other reason why you should not participate? If you answered YES to any of these questions please give details on another page. Assumption of risk I hereby state that I have read, understood, and answered honestly the questions
Transcript of · Web viewCONTINUE BELOW PLEASE. If you answered YES to any of the questions above, please give...
Physical Activity Readiness Questionnaire (PAR-Q)
Name: DOB:Sex:
Address:
Telephone: MOB:
Email: Emergency contact Name & Tel:
Common sense is your best guide for answering these questions. Please read them carefully and answer Y or N opposite the question as it applies to you.
Questions Y/N
1) Do you have a bone or joint problem that may be aggravated by physical activity?2) Do you suffer from High Blood Pressure?3) Do you suffer from Low Blood Pressure?4) Is there a history of Coronary Heart Disease in your family?
5) Is your doctor currently prescribing you drugs or medication?
6) Do you suffer from shortness of breath at rest or with mild exertion?7) Do you have chest pains brought on by physical exertion?8) Do you ever feel faint, have spells of severe dizziness or have lost consciousness?
9) Do you drink more than the average amount of alcohol per week (21 units for men/14 units for women)?
10) Do you currently smoke?11) Are you, or is there any possibility you might be pregnant?12) Are you over the age of 45 years?13) Do you know of any other reason why you should not participate?
If you answered YES to any of these questions please give details on another page.
Assumption of risk
I hereby state that I have read, understood, and answered honestly the questions above. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise, High Intensity Interval Training and stretching. I realise that my participation in these activities involves the risk of injury and even the possibility of death. I agree to advise the Bootcamp Instructor if there are any changes in my medical condition and understand that the Bootcamp Instructor will not be liable for any injury or illness that may occur.
Participant signature:
Bootcamp Instructor Signature:
CONTINUE BELOW PLEASE
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If you answered YES to any of the questions above, please give more details below:-
How did you hear about Carpe Diem ie: Spotted the Carpe Diem Car / Word of Mouth / Search Engine?
Do you currently exercise?
If yes, what do you do?
Thank you for filling in this questionnaire.
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