Disclaimer - Read first before taking advice

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Disclaimer - Read first before taking advice

Postby Canuck Singh » Thu Jan 29, 2009 4:53 pm

The following is a standard pre- activity questionnaire. In no way is this medical advice, and before undertaking any advice from this forum or any of the forum users, please see your general health practitioner and explain any exercise or strenuous activity that you plan to undertake first:

ParQ Health Questionnaire RD 122


Please read the questions carefully and answer each one honestly, ticking the appropriate box or adding information if necessary. Your responses will of course be kept in the strictest confidence. This form must

be completed, returned to a Fitness Advisor and assessed prior to availing of any induction services.

Name: __________________________________________ Postcode: ____________________

Contact tel no (mobile preferred) email
Has your doctor ever said that you have had a heart problem?
No ☐ Yes ☐
In the past month have you had any chest pain when…
You were doing any activity No ☐ Yes ☐ You were resting No ☐ Yes ☐

Are you currently taking medication for…
A heart condition No ☐ Yes ☐
Any other problems No ☐ Yes ☐

Do you suffer from any bone or joint problems?
No ☐ Yes ☐

In the past year have you had any major illness or major surgery?
No ☐ Yes ☐

Have you ever been diagnosed with…
Diabetes No ☐ Yes ☐ Asthma No ☐ Yes ☐
Epilepsy No ☐ Yes ☐ Other problems No ☐ Yes ☐

Are you pregnant? Have you recently had a baby?
No ☐ Yes ☐ EDD No ☐ Yes ☐ How long ago?

Do you ever…
lose your balance because of dizziness or lose consciousness No ☐ Yes ☐

Are you feeling unwell at present due to cold, etc
No ☐ Yes ☐


If you have answered YES to one or more questions we may need you to contact your doctor before starting to exercise. If your health changes so that you may then answer YES to any of these questions, tell a member of staff as soon as possible.

I have read, understood and completed this questionnaire.

Any questions that I had were answered to my full satisfaction.
Signature: ____________________________________ Date: _________________
Signature of Parent/Guardian (if aged 16 – 17) __________________________________

or download here:
par_q.pdf
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Canuck Singh
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Location: Vancouver Canada
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