01432 271576

Timetable

COVID Plan

PAR-Q

Physical Activity Readiness Questionnaire

PAR-Q

Participant Details

First Name *

Surname *

Date Of Birth

GP Surgery

Emergency Contact Name

Emergency Contact Number

PAR-Q

By answering this PAR-Q it will allow you to identify whether you should check with your doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being physically active, check with your doctor before participating. Please read carefully and answer each one honestly. Common sense is your best guide when answering these questions. Please fill in YES or NO, some answers may require additional details

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

Please provide further details of your heart condition

Please could you provide further details

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

Please provide further details of your chest pain during physical activity

Please could you provide further details

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

Please provide further details of your chest pain during non-physical activity

Please could you provide further details

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

Please provide further details of your dizziness or loss of consciousness

Please could you provide further details

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

Please provide further details of your bone or joint problem

Please could you provide further details

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

Please provide further details of your medication for your heart condition/blood pressure.

Please could you provide further details

Is there any chance you might be pregnant? *

Congratulations! Please provide details regarding your pregnancy

i.e. How many weeks pregnant

Have you ever had any chest complaints (Asthma)? *

Please provide details regarding any chest complaints

Do you smoke? If so for how long and how many per day? *

Please provide details regarding how long and how many times per day you smoke

Have you ever had surgery? *

Please provide details regarding any surgery history

Do you have any allergies? *

Please provide details regarding any allergies

Have you ever been diagnosed with diabetes? *

Please provide details regarding your diabetic history

Have you had Covid-19 *

Have you experienced what you consider to be any sings or symptoms of long covid? If not, have you noticed any changes to your normal level of energy or exercise that has been altered or seems to of worsened since your exposure to the virus?

Ensure you include: Condition, Original Onset and Details

Have you had the vaccine? *

Do you suffer from any previous medical conditions or injuries? *

Please provide details regarding medical conditions or injury history

Ensure you include: Condition, Original Onset and Details

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

Please provide details regarding why you should not do physical activity

Blood Pressure

Systolic/Diastolic (mmHg)

Heart Rate (bpm)

Declaration

You may need to consult with your Doctor to clarify whether you are safe to become physically active at this current moment in time and in your current state of health. You may need to restrict your activities to those which are safe for you. By signing this form you agree to us contacting your GP to obtain clearance for you to begin a training program.

If you answered no to all questions then you are reasonably safe to participate in physical activity. Start by gradually building up from your current ability level. A fitness assessment can help determine your ability level.

I have read, understood and accurately completed this questionnaire. I can confirm that I am voluntarily engaging in an acceptable level of exercise and my participation involves risk of injury. If I have answered YES to one of the above, we may need to consult with your Doctor to clarify whether you are safe to become physically active at this current moment in time and in your current state of health. We may need to restrict your activities to those which are safe for you. Please note: If your health changes so that you answer YES to any of the above questions, please inform us immediately. It may be recommended that you change your exercise program. By completing this form you give us permission to contact your GP if required.

As an under 18 year old we need the signature of a parent or guardian to complete this form. Please note that in order to provide a safe training environment we require a parent or guardian to be present when there is only one member of staff on shift. Upon arrival please check this with the coach taking the session.

Signature *

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Contact Us

01432 271576

Rotherwas Gym
Unit 2, Clearview Court, Twyford Road,
Hereford, HR2 6JR

City Gym
Edgar Street, Hereford, HR4 9JU