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PAR-Q Form

Client's name: DOB: Contact No. Email: Next of kin: Next of kin's contact no.

If you are the planning to take part in physical activity or an exercise class, start by answering the

questions below. If you are between the ages of 15 and 69 the questionnaire will tell you if you should

consult with your doctor before you start. If you are over 69 years of age, and you are not used to

being very active, check with your doctor.

All information will be treated confidentially. Yes No

1. Has your doctor ever said you have a heart condition and that you should only do

physical activity recommended by a doctor?

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

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

4. Do you ever feel faint or have spells of dizziness?

5. Do you have a joint problem that could be made worse by exercise?

6. Have you ever been told that you have high blood pressure?

7. Are you currently taking any medication of which the instructors should be made

aware?

7a. If yes, what?

8. Are you pregnant or have you had a baby in the last six months?

9. Is there any other reason why you should not participate in physical activity?

9a. If yes, what?

If you have answered ‘YES’ to one or more questions:

Talk to your doctor by phone or in person before you start becoming more physically active and

before you have a fitness assessment. Tell your doctor about the questionnaire and which question(s)

you answered yes to. You may be able to do any activity you want – as long as you begin slowly and

build up gradually – or you may need to restrict your activities to those which are safe for you. Talk

with your doctor about the kind of activity you wish to participate in and follow his/her advice.

If you have answered ‘NO’ to all questions:

You can be reasonably sure that you can start to become more physically active and take part in a

suitable exercise programme. Remember – begin slowly and build up gradually.

Client’s Name Date:

Witness Name Date:

Informed Consent Form

The purpose of an exercise programme is to help you to achieve health and fitness goals.

You will be set a programme based upon your present activity/exercise levels and your stated

goals. You will experience some feelings of exertion during each activity session and may

become hot and uncomfortable at times. If your plan includes certain types of cardiovascular

exercise you can expect your breathing to become more rapid and your heart rate to increase.

As your fitness improves, your goals may lead you to participate in more vigorous levels of

activity but these should remain within your capabilities.

All activities will be explained and demonstrated to you but you should feel free to ask any

questions you may have. Any exercise programme carries with it an element of risk. The

sessions are designed to minimise risk yet, at the same time, provide an effective exercise/

activity programme. Please inform the instructor if there is any reason why you should not

participate in an activity i.e. if you have an illness or an injury which might be aggravated by

exercise.

If, at any time, you feel undue pain or excessive discomfort stop the activity immediately and

inform the instructor of your symptoms. You are free to withdraw from any activity at any

time you wish.

I agree to take part in the programme described to me by the instructor. The nature,

purpose, risks and benefits have been explained to me and I understand what is required of

me and that I may withdraw at any time.

Client:

Witness:

Date: